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Dr. James Downar is a thoughtful, engaged and passionate teacher. Especially about death—or palliative care to be precise.
When he first started medical school at McGill, Dr. Downar stated definitely in his goals that he was not interested in palliative care. But working with palliative care physicians and caring for dying patients convinced him otherwise.
After graduating in 2002, he now has three specialties: palliative care, critical care and ethics. He brings all three together in his work at the ICU and on the palliative care service at TGH.
"When you are dealing with critically ill patients, there is a huge overlap in these areas," he says, explaining that the framework of ethics and palliative and supportive care can be usefully brought into the ICU when patients and families are at a critical decision point, and are frightened, paralyzed with deep emotions or unsure of how to proceed.
He is committed to helping health care specialists and patients with end-stage, incurable diseases communicate better, so that patients and families are better prepared to make the best end-of-life decisions that reflect the wishes and values of patients and medical reality.
To this end, he has been running a communications workshop for ICU trainees for five years, which incorporates difficult simulated family meetings designed to prepare future ICU doctors for talking to family members of a critically-ill person. Data shows that these workshops are effective, and Dr. Downar hopes to broaden them out to other specialties and settings.
He has also helped to prepare recommendations to the Parliamentary Committee on Palliative and Compassionate Care in Canada, emphasizing that many incurably ill patients are admitted to ICU, which is not helpful to either patients or families, and that many are unprepared to deal with a progressively worsening illness ending in death.
Dr. Downar wants to get the message out that palliative care is a good option for those patients who are nearing the end of their lives, because it is active, supportive care, aimed at controlling symptoms and providing quality of life and dignity.
Comfort measures do not shorten life, he emphasizes, pointing out that in some cases, such measures may even prolong survival for end-stage cancer patients.
"It is easy to see how you can add value to a person's life even if life-sustaining measures are no longer an option," he says.
Simple changes in medication or radiation treatment for pain can make a huge difference to a dying person, he explains, adding that important conversations, last wishes and thoughts can still be communicated in those final days, offering a chance for the patient to reflect and achieve a state of peace and calmness.