Fostering Interactions That Heal

Eduardo Bruera, MD, FAAHPM, does not have a favorite book. Every time he finishes a new book, that becomes his favorite until he begins another story. He is constantly enthused by what is new.

His commitment to the new has translated to the palliative care in oncology programs that he envisioned and eventually helped bring to life. Among his accolades, Bruera founded the first academic fellowship program in palliative care at the University of Alberta in Canada. Later, while working at The University of Texas MD Anderson Cancer Center in Houston, Bruera established the institution’s Department of Palliative, Rehabilitation and Integrative Medicine, which has flourished into the largest clinical and academic palliative care program in the world.

Bruera is credited with the development of the Edmonton injector in 1991, a device designed for the subcutaneous injection of narcotics that allows patients freedom from potentially uncomfortable intravenous poles. He also took part in developing the Edmonton Symptom Assessment System—a questionnaire used to rate the intensity of 9 common symptoms experienced by patients— before patient-reported outcomes were an accepted component of cancer care.

At the time it was developed, Bruera made it free of charge for anyone to use.

Since then, the tool has been translated into 60 languages, underscoring the impact of his contribution and allowing many more patients’ experiences to be included on their own health record.

“Bruera has been instrumental in integrating palliative care with routine oncological care that we currently see in North America and worldwide,” said Akhila S. Reddy, MD, associate professor of palliative, rehabilitation, and integrative medicine at MD Anderson. “His work has shaped the practice of current-day palliative medicine.”

A true visionary, Bruera’s ultimate goals stretch far beyond his institution.

“I hope [to see] every single cancer center that has an intensive care unit also have a palliative care unit,” he said, noting that just as every person’s life is different, so are their deaths. “Some patients will have a rather uneventful end of life; others will have an excruciatingly painful and lonely end of life. The palliative care unit is for those patients.”

Eager to Make a Change

Growing up in Rosario, Argentina, Bruera was surrounded by and interested in medicine. His father was a cardiologist and he was raised hearing stories around the dinner table about his father’s work experiences. He explained that although his father was very private and would never disclose crucial details about his patients, what he did share hooked Bruera: He could see the passion his father had for helping people feel better. While Bruera knew he wanted to also be a doctor, his specialty remained unclear for years.

When his father started his cardiology career, it was considered a bit of a pioneer specialty. However, by the time Bruera was enrolling at the Universidad Nacional de Rosario in the 1970s, he felt that cardiology had made many advances and was no longer the ideal place for a young trailblazer. Ambitious and eager to make a change, he found himself drawn to oncology, which was then a bit of an outlier.

“At that time, cancer was the disease that everybody feared enormously. My mom would not even pronounce the name “cancer” for many years, even after I was an oncologist,” Bruera said, smiling. “She would tell her friends that I was in a bad field. There was a big taboo.”

In many ways, oncology was a ripe field for study; the science was cutting-edge and the need was plentiful. Bruera was eager to uncover new ways to stop disease progression and improve outcomes. But when he began his rotation in clinical oncology, he was startled by the suffering he observed. He realized how ill-equipped he was to deal with the human side of cancer care.

“I never started oncology truly thinking about the person,” he admitted. “I was fascinated by ways in which we might kill the tumor or change the trajectory of illness of the patients. And then I started doing my rotations.”

Two patients in particular left Bruera feeling helpless. He cited the case of a mother in her 30s whose breast cancer had metastasized to her bones. Sadly, her pain was so severe that she could no longer lift her child.

“The child would raise their hands for mommy to pick them up and she just could not,” he explained. “The small baby could not understand why mom was rejecting him.”

Bruera explained that, at that time, the discourse surrounding pain was that it was “normal,” especially for patients with metastatic disease. However, the case of this young mother helped him see that “normal” is an insufficient answer when people are suffering.

Another patient who left a lasting impression on the young doctor was a woman in her early 60s with ovarian cancer who was experiencing episodes of ascites-induced abdominal swelling. That patient taught him how to find meaning in life even in the face of terminal illness.

“I felt life would not have any meaning to me if I was in her situation, but she did find meaning in lots of things, even at that stage in her disease,” he said. “So if she found meaning in a conversation with a relative, in watering her plants, in seeing a bird, or even having a conversation with me, I needed to make sure that I found meaning in helping her.”

The way he saw it, he and his team were so focused on treating the cancer that they were not focused on treating the person. Several patients left him with this impression and so, while many of his colleagues remained fixated on the science behind the tumors, he felt his interests gravitating toward supportive methods of care.

He decided to pursue palliative medicine, but knew he had to leave Argentina to do so.

Leaving Home

Bruera began sending letters. He received a letter of potential interest from Neil MacDonald, MD, then director of the division of oncology at the University of Alberta, in Edmonton, Canada.

“He said, ‘I think what you are proposing is of interest. Come down for a year and we will see what we can do together,” he recalled. “I accepted that [offer] and what was supposed to be a 1-year [term] became 15 years.”

During his time in Edmonton, Bruera made numerous professional contributions. He designed one of the first palliative care programs in the world. Much of his work was focused on optimizing pain medications; mitigating toxicities including nausea, depression, and anxiety; and improving patients’ overall health status by optimizing their nutrition and other health factors that determine quality of life.

He also helped create the Edmonton Classification System for Cancer Pain, which allowed oncologists to standardize the assessment and classification of cancer patients. Further, it prompted the development of personalized pain interventions tailored to an individual’s pain profile.

In 1999, Bruera received a call from MD Anderson, which offered him the opportunity to come to Texas. He was very excited to bring his work to the main stage at one of the most renowned cancer centers. He has been there for 24 years, and except for the hurricanes, he loves everything about living in Texas.

In his current role, Bruera does “a little bit of everything.” However, spending time in the clinic is at the heart of what he loves.

“I love my clinical activity,” he said. “The source of meaning in all the other aspects is brought by the clinical activity. I learn so much from my patients— what works, what does not work, what makes them happy and what makes them unhappy.”

He also loves the clinical research process. He dedicates a fair amount of time to writing grants and papers and mentoring junior faculty. He meets with the fellows, teaching them about 5 times a year, and holds a journal club for them 3 times a week. He also moderates the weekly grand rounds and weekly fellow and faculty rounds.

“I have a very close contact with our fellows. The main reason for that is they are our future faculty. They are also the future of the field,” he said.

Support and Controversy

MacDonald was a gigantic figure in the trajectory of Bruera’s career, encouraging his efforts in palliative care.

“He was instrumental in my career pathway because he basically said, ‘Let’s try,’” Bruera said, noting that, at that time, palliative care was not a common field of study. “He said, ‘I’m not sure I have a tremendous amount of experience in this, but I think it is important.’”

Not everyone had the same perspective toward palliative care as MacDonald. Bruera recalled feeling hostility directed toward him from other colleagues. Luckily, MacDonald stood up for him and his research, allowing him a safe space to pursue this work.

“He played a little bit of interference,” Bruera said. “At that time, people who were very focused on cancer treatment thought we were a waste of time, resources, and pay. They would tend to not be that friendly. But those same people needed to go to the cancer center director when they needed beds and positions. He would tell them, ‘I see you need this, but be nice to Eduardo.’”

Commitment to Healing

Eventually, Bruera was able to get his colleagues to see palliative care as both a science and a discipline.

“Delivering supportive and palliative care is a complex activity; it is a complex intellectual challenge,” he explained. “It is not just a matter of being nice, it is not a touchy-feely area. Of course, kindness is important. But you need to know how to do it, you need to know what medications [work], you need to know which words [to use], and you need to know which body posture works and heals. That requires a similarly, or even more, disciplined approach as the biomedical aspects of cancer care.”

“Bruera is a luminary who has made countless major scientific contributions to the field,” said Daniel E. Epner, MD, FACP, professor of palliative, rehabilitation, and integrative medicine at The University of Texas MD Anderson Cancer Center. “He is a prolific educator and highly successful administrator who built our department exponentially over the past 20-plus years into what is one of the largest—if not the largest—palliative medicine department in the world, with nearly 30 physicians, many doctoral-level psychologists and researchers, nearly 20 advanced practice providers, and several million dollars in federal funding.”

Additionally, he has deepened the field’s understanding of autonomic failure in advanced cancer, led the development of hypodermoclysis and proctoclysis as methods of hydration, and pioneered the use of methadone for the management of cancer pain.

Bruera has helped to establish numerous palliative care programs in Latin America, India, and Europe. He has held leadership roles with the World Health Organization, the Multinational Association of Supportive Care in Cancer, and the International Association for Hospice and Palliative Care.

Asked about his greatest achievement, he said he is particularly honored by the fact that both the Canadian Society of Palliative Care Physicians and the Latin American Association for Palliative Care have created an Eduardo Bruera Palliative Care Award.

“I found this quite moving, but it also puts a little bit of a responsibility [on me],” he said. “I need to stand up to that level. I need to maintain my professional and my ethical standards so that I am worthy of those awards.”

Aside from being a pioneer in the field of palliative care, Bruera is an opera aficionado, an avid cyclist, and a loving father to his children, Eduardo, Sofia, and Sebastian. Most of all, he is committed to the power of healing, a responsibility threaded both within and beyond the walls of the clinic.

Balfour Mount, MD, a Canadian physician who is credited with inventing the term “palliative care,” once said that no human interaction is neutral; each interaction is either healing or harming. Bruera said he has taken this as a guide through life, applying it to every airplane conversation, opening of a door, or order at a restaurant in addition to his clinical and medical care.

“I’m trying to make every single interaction in my life a healing interaction,” he said.