On death and dying
So yesterday I spent my day at the Massachusetts Medical Society House of Delegates meeting. After the meeting (which was about half a day), there were a couple of continuing education talks. The first was on Gender violence in the Sudan (by a physician and minister, Gloria White-Hammond), and it was a tough talk to hear, as several present noted. The second talk was on "The Current State of Palliative Care". And the answer, especially in Massachusetts, is "parlous". (Means "not good"). Mind you, it's not a lot better most other places; a few standouts exist, but we're only now starting to have training programs (there's one in MA, at the Mass General), and lots of training is OJT.
But that said, there seems to be a need for the combination of hospice and routine care. Little known fact about hospice: if you want hospice care, you must give up on any other curative treatment. Interestingly, as a result the uptake of hospice is low and happens late. In programs where they've tried what's called "concurrent care" (where hospice and routine, curative care are both allowed), there is *much* more uptake, and furthermore, most of the people (on the order of 70%) who start the program stop curative treatment soon after starting, and get to work on palliation (which is not strictly curative, but focuses on making you feel better now, even if it costs some months of life later). And it seems that people who stop looking for a cure, and seek palliation, live *at least* as long, and on occasion *longer*, than those who continue to seek a cure.
I personally suspect that the thing which makes hospice unattractive is the requirement to give up treatment options. Especially in America, people hate to give up options. But we can also be hardheaded about which options we choose when we have all the facts available. And here's where physicians come in; I think we need to do a lot more training regarding how to handle end of life issues, and a fundamental change in outlook in the culture of physicians regarding how to handle these matters.
From Atul Gawande:
"The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end."
Read more http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande#ixzz179jE1RL4
And another issue which will come up, inevitably, is funding. Payment for these discussions (which can be very long) is not guaranteed-there isn't really a CPT code for it, etc. This funding was what was under discussion during the "death panel" controversy some while back. And we all know how well that went. Hopefully, as a society we can make this discussion happen soon, and with a bit more light and less heat, than the prior discussion did.
But that said, there seems to be a need for the combination of hospice and routine care. Little known fact about hospice: if you want hospice care, you must give up on any other curative treatment. Interestingly, as a result the uptake of hospice is low and happens late. In programs where they've tried what's called "concurrent care" (where hospice and routine, curative care are both allowed), there is *much* more uptake, and furthermore, most of the people (on the order of 70%) who start the program stop curative treatment soon after starting, and get to work on palliation (which is not strictly curative, but focuses on making you feel better now, even if it costs some months of life later). And it seems that people who stop looking for a cure, and seek palliation, live *at least* as long, and on occasion *longer*, than those who continue to seek a cure.
I personally suspect that the thing which makes hospice unattractive is the requirement to give up treatment options. Especially in America, people hate to give up options. But we can also be hardheaded about which options we choose when we have all the facts available. And here's where physicians come in; I think we need to do a lot more training regarding how to handle end of life issues, and a fundamental change in outlook in the culture of physicians regarding how to handle these matters.
From Atul Gawande:
"The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end."
Read more http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande#ixzz179jE1RL4
And another issue which will come up, inevitably, is funding. Payment for these discussions (which can be very long) is not guaranteed-there isn't really a CPT code for it, etc. This funding was what was under discussion during the "death panel" controversy some while back. And we all know how well that went. Hopefully, as a society we can make this discussion happen soon, and with a bit more light and less heat, than the prior discussion did.