Letting go: Atul Gawande on Palliative Care

[DrDrToBe]

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A classmate just sent me this article, it's put's palliative care into an eye-opening perspective, and should be a great read for anyone in the medical field.

http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?printable=truehttp://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?printable=true

Would love to hear your thoughts!

 

[Morsetlis]

I had to read that article for a class.

It was too long.

 

[Isoprop]

This is an absolutely fantastic article. I remember reading this last year when it was published.

Hospice is probably one of the most misunderstood medical specialties. To a lot of health care workers, it looks like hospice is that "place you go to die" or "the field where they give up on you." I remember talking to a med student, and I asked her if she was interested in hospice (we both were shadowing there). She told me that she wouldn't because there's never a "win" in hospice.

I never agreed with this. I think a death in hospice is a "win." The alternative might have been dying in an ICU on a vent with tubes and IVs everywhere slowly turning into mush and crashing.

There's a quote from a hospice doc in this thread that I really love:

Sure, we try to put out fires. But, if we can't put out the fire, a good physician takes the patient's hand and walks with him through the flames.

 

[tiedyeddog]

That article was great.

 

[pingouin]

Thanks for sharing- excellent article.

I'm just starting to read his stuff, and I'm really digging it so far. The first thing I read was The Hot Spotters, which was in the New Yorker in January (there was a recent thread on here). Then a friend lent me his first book, Complications, and I just finished that. Truly excellent. Now I need to start Better, which she also lent me.

 

[JimmyChitwood]

After that you have The Checklist Manifesto. I've read all his stuff and think he's great.

 

[jdh71]

He's good and the piece of hospice excellent. I like him because he's thoughtful. As embarrassing as it for me to say, his stuff has changed some of my outlook and practice.

 

[DrDrToBe]

This article really struck a nerve with me; I am currently on the wards and even though I am just a medical student, my patients often ask me questions on prognosis, complications, "Am I going to die" etc, and in those cases it's really difficult for me to answer honestly, and as embarrassing as it is to admit most of the times I defer to the team. That's definitely something I'm trying to work on, and this article reminded me of that.

 

[thesauce]

While I agree with the premise of the article, some of the details were blatantly wrong. In particular, the inferred goal of whole brain radiation therapy and some of the side effects (immune compromise and inability to clear secretions) that they attributed to this regimen. The 5 day course of radiation she received was palliative - it was not intended to be curative.

 

[DoctwoB]

While I agree with the premise of the article, some of the details were blatantly wrong. In particular, the inferred goal of whole brain radiation therapy and some of the side effects (immune compromise and inability to clear secretions) that they attributed to this regimen. The 5 day course of radiation she received was palliative - it was not intended to be curative.

It was only palliative in the sense that her other late chemotherapeutic regimens were palliative. Cure wasn't possible, but the WBRT could extend life somewhat and reduce symptoms, though Gammknife probably would have been better.

 

[aSagacious]

Interesting read. I might be missing the forest for the trees but Gawande seems to contradict himself in his conclusions.

He first supposes that patients (and their family members) are unfit to make rational decisions in these types of situations due to their lack of medical knowledge, emotional investment, and blind hope.

He later suggests that physicians should discuss priorities with patients before constructing a course of treatment. This is absolutely understandable and certainly advisable for those who want to optimize their quality of life near the end.

The problem, of course, lies with the not-insignificant population that decides to pursue 'curative' treatments at all costs. In this case there are very good arguments for either giving authority to the physician or the patient.

Gawande appears to prefer leaving the decision to the physician at the end of the essay, but only after going back and forth more times than I can count. So, supposing we end up with a system where doctors have the final say in whether or not to pursue aggressive treatment (sometimes contrary to the wishes of the patient), where should the cutoff be? 5% 6 month survival rate? $100,000 aggregate treatment cost? Diminishing in quality of life to some arbitrary point?

 

[jdh71]

So, supposing we end up with a system where doctors have the final say in whether or not to pursue aggressive treatment (sometimes contrary to the wishes of the patient), where should the cutoff be? 5% 6 month survival rate? $100,000 aggregate treatment cost? Diminishing in quality of life to some arbitrary point?

I don't think setting some sort of arbitrary cut-off is any better than simply allowing for professional medical opinion to decide

 

[loveoforganic]

It takes more than great doctors counseling on end of life care to change the society with great belief in the power of technology (medicine included) and a general reluctance to genuinely acknowledge death as a reality and bring it up for discussion. So caregivers/loved ones end up stuck decision-making for dad or mom after a stroke or mi or whatever puts them in the hospital and unable to communicate with no former desires even mentioned regarding intubation, rib cracking CPR, etc. There needs to be a more large scale public health effort to change societal beliefs.

As far as cutoff measures - measuring QoL is a very sticky thing.

 

[aSagacious]

I don't think setting some sort of arbitrary cut-off is any better than simply allowing for professional medical opinion to decide

Agreed, but in this essay Gawande seems to suggest that, when left to their own biases, physicians often pursue treatment against their better judgement. He argues that this lapse in judgement is partially responsible for the recent increases in cost of end-of-life care and associated decreases in quality of life for an extended period. I don't necessarily think that generic guidelines are the answer, but perhaps recommendations of some kind would be helpful as a reference when physicians are making difficult or unpopular decisions.

 

[loveoforganic]

I have a q about payments - depending on insurance plan, do patients have a near unlimited (until try reach lifetime/annual cap) resources to put in to eol care? When those resources run out, does Emtala hold the hospital responsible for sustaining eol care as long as the caretaker desires?

 

[thesauce]

It was only palliative in the sense that her other late chemotherapeutic regimens were palliative. Cure wasn't possible, but the WBRT could extend life somewhat and reduce symptoms,

I'm not entirely sure what you're saying here. The only time WBRT isn't palliative is when it's given prophylactically.

though Gammknife probably would have been better.

Why? SRS to each of 9 metastatic lesions?

 

[jdh71]

Agreed, but in this essay Gawande seems to suggest that, when left to their own biases, physicians often pursue treatment against their better judgement. He argues that this lapse in judgement is partially responsible for the recent increases in cost of end-of-life care and associated decreases in quality of life for an extended period. I don't necessarily think that generic guidelines are the answer, but perhaps recommendations of some kind would be helpful as a reference when physicians are making difficult or unpopular decisions.

That's a good point. I see that bias in myself as well sometimes - the "maybe there's a chance if we do this" kind of thing.

One thing is clear, we spend a lot of money on end of life care, and probably much (too much?) of that on things that we really shouldn't if we were all honest with ourselves.

 

[DoctwoB]

I'm not entirely sure what you're saying here. The only time WBRT isn't palliative is when it's given prophylactically.


Why? SRS to each of 9 metastatic lesions?

Haha, I didn't see the number of lesions. Fair point.

 

[ucsfstudents]

Some physicians are just better at coming to the decision to let go. It is then an art to allow the family to come to the same conclusion you have.. that's it's time to let go.

 

[Isoprop]

I have a q about payments - depending on insurance plan, do patients have a near unlimited (until try reach lifetime/annual cap) resources to put in to eol care? When those resources run out, does Emtala hold the hospital responsible for sustaining eol care as long as the caretaker desires?

From my little experience, it seemed most hospice services were covered by medicare. I've never run into a hospice patient who wasn't paying through medicare. Also, I believe EMTALA isn't really applicable because all of the patients are DNR... which I believe is a requirement to receive most (but not all) of hospice benefits.

There's not really a cap, but there are definitely restrictions on coverage. I remember a lot of patients didn't get coverage for antibiotics. In the end, hospice medicine is very cost-effective. Life-saving procedures and heroic attempts to save lives are expensive... much more than some pain meds.

 

[loveoforganic]

Sorry, I didn't realize it, but I was pretty unclear with my question because I was kind of misusing "eol care." I had intended to ask about intubation, ventilation, etc., i.e. "life prolonging" eol care.

 

[Isoprop]

Sorry, I didn't realize it, but I was pretty unclear with my question because I was kind of misusing "eol care." I had intended to ask about intubation, ventilation, etc., i.e. "life prolonging" eol care.

If we're talking about hospice, there is none of that. For example, if a patient is on a vent is decided to be put on hospice, I believe the first thing that is done is to ween that patient off the vent.

There is no "life prolonging" in hospice. I mean, we're not KILLING the patients, we're just making them comfortable while they die.

 

[loveoforganic]

I'm a pretty sucky communicator. I mean the current nation norm - in the hospital, not the hospice.