the time before dying

[freelancewriter]

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Just read an interesting med student letter/article on the US News Website. Thought I would share:
"From the doctor's viewpoint, he had exhausted all treatment options and that was the end of it. Yet the patient, who was dying of cancer, asked if he might continue to come in every week anyway, since he found the visits comforting. But the doctor felt he had nothing left to give him, and turned him away."
http://www.usnews.com/usnews/issue/040419/health/19rachel.htm

 

[drboris]

I think that writing about death and our experiences for ten minutes and then sharing will help open all of us up, and do a lot of good.

 

[roballan14]

I am a Catholic minister hoping to enter medicine in the next few years. One of the areas of my work that I enjoy most is helping people and families near the time of death.

There are two issues at hand here 1) healing a patient 2) curing a patient.

Curing is certainly your job; in that medicine is geared toward returning someone's body to homeostasis. It's what you all are best at.

Healing, in the other hand, is helping a patient accept disease (death) in a way that is comforting. For many, the catalyst for that acceptance is religion, but for others it is the thought of having contributed to society, taught something special, etc.

As a minister I can see where physicians feel that they are done when curing is deemed impossible that they ought to leave the picture; but may I suggest that patients would love it if you would stick around for the healing/acceptance/non-medical part. While you may not be trained for that, a good hospital chaplain or your own pastor or the patient's pastor can make you an important part of the healing process.

 

[Seaglass]

Yes, many people don't realize the important place trained chaplains have in hospital health. I recently learned in my spirituality and health senior seminar that chaplains have to do about as much post graduate training as doctors: 3 years seminary then 1-3 years of residency.

C

 

[Kalel]

There are two issues at hand here 1) healing a patient 2) curing a patient.

Curing is certainly your job; in that medicine is geared toward returning someone's body to homeostasis. It's what you all are best at.

Healing, in the other hand, is helping a patient accept disease (death) in a way that is comforting. For many, the catalyst for that acceptance is religion, but for others it is the thought of having contributed to society, taught something special, etc.

As a minister I can see where physicians feel that they are done when curing is deemed impossible that they ought to leave the picture; but may I suggest that patients would love it if you would stick around for the healing/acceptance/non-medical part. While you may not be trained for that, a good hospital chaplain or your own pastor or the patient's pastor can make you an important part of the healing process.

I agree that chaplains play a great role in helping patients who are dying in the hospital deal with their death. I do think that believing that a physicians role in healthcare is to "cure patients" is a common misconception that most of the general public has, particularly in matters regarding death. A physician's work is just prolonging the inevitable, and part of our job is just to make the process of the inevitable death a less painful process and to help the patient get the most out of life as possible. I get frustrated with the number of patients who I see who spend their last few weeks/months lying in hospital beds, being poked and prodded with painful procedures that ultimately, will have no effect on their outcome or at best, buy them a few weeks of a more painful death rather then the peaceful one we averted. The attitude that all dying patients should die in the ICU is a common misconception that physicians hold as well. I think that physicians are getting better at offering things like hospice care and telling patients that last-minute heroics may not be the best course of action, but there is still a lot of progress that needs to be made in this arena, partly through the medical education process. The legal system is partly to blame here too, since many physicians will offer (sometimes almost force) the most invasive procedures to patients (and who are patient's and their families to turn them down when they don't know any better) with the idea that the greater the invasiveness and aggressiveness of their medical therapy, the less likely that the patient's family can come back and sue them for not doing everything possible to save their loved one. I was actually recently talking with an attending about this too, and he was saying how it usually takes a patient to see a family member going through the whole process of death within a hospital to realize that hospitals aren't necessarily the best place to die. If you talk to a lot of physicians, they will tell you that the last place that they'd like to spend their last few days is in a hospital; it's unfortunate that we can't convince more of our patients to see things our way.

 

[Dr. J?]

roballan14, drboris, et. al.,

I too have had experiences within the hospital (as a provider in the ED and as a family member of a seriously ill pt) which reinforce the need to strive for both 'curing' the pt and 'healing' the pt. I have seen on numerous occasions how integral hospital chaplains are in helping pts adjust to the new reality of being ill. I have much respect for the work they do -- in many respects their job is more difficult than the treating physicians.

For those who have dealt with this and have experiences to speak from, I think it would do a world of good for the younger members of the forum to hear what you have to say. Also, if any resources exist which may help junior med students to become more knowledgeable about the issues at hand, please bring them to our attention.

 

[roballan14]

Dr. Stephen Kalish has a great book called "Death, Grief, and Caring Relationships". It covers all the mechanisms through which families cope with death (religion, generativity, etc) and discusses provider roles. The text is intended for the academic setting and thus may lack the personal touch, but it is a required resource for grief therapists. I think you would find it helpful.

Dr. Gerald Lewis also had a book called "Critical Incident Stress and Trauma in the Workplace". This text deals more directly with the feelings a provider may experience during loss of a patient/s rather than suggesting strategies for assiting families. But it is a great work especially for medical folks who deal with forms of violent or sudden death. 😉

 

[freelancewriter]

Another great read, this time a San Fransisco Chronicle article:

"Hospitals around the country are trying to make the ICU a better place to die.

The intensive-care unit is a high-tech environment dedicated to saving lives. But the reality is that about 20 percent of all U.S. deaths occur there in the midst of its blinking monitors, ventilator tubes and busy white-coat clad staff. Hospitals are increasingly devoting more resources to making those who die there more comfortable. The goal is to achieve a peaceful death in which a person slips away surrounded by family and friends.

The new approach, called palliative care, is a sharp clash with the traditional focus of ICUs..."

20% of U.S. deaths in ICU - yikes! I went to visit my wife's grandma in ICU in St. Louis, and during the 20 minutes we were there we witnessed the death of two people. The description of machines everywhere and scurrying, white-coat clad staff is still etched into my brain. (It was a circular area with a nurses station in the middle, and "rooms" with curtains for doors on the perimeter. I don't know if this is the norm.)

I still envision her hooked up to machines, and wonder how many strangers were around when she died a few days later. It's an image that's difficult to erase.

Take me out of ICU and let me die in a warmly decorated hospital room surrounded by friends and family instead of machines. Or send a doctor to my house to give me pain meds, and let me die at home.

Full article: http://www.sfgate.com/cgi-bin/artic...04/04/13/financial1049EDT0077.DTL&type=health

 

[kinetic]

Death is a hard topic to touch because there is so much emotion attached to it (and this is not unjustified). However, most people - educated or not - throw logic out the window when emotions come into play (which is why physicians don't take care of their relatives or spouses ...you'd order every test under the sun every time your son said he had a one-day non-productive cough).

I have heard from a number of sources that America spends something like 90% of all health care dollars in the last 1-2 years of a patient's life. Think about that. All of our health care resources are funneled into whacking Death on the knuckles when it comes to take us away. We all talk a good game about "quality of life is more important than quantity" but when push comes to shove almost all of us take quantity. How many families have you seen refuse to sign a DNR on a 90-year-old patient with COPD, terminal metastatic cancer, or fulminant hepatic failure? (And how many of you are thinking that I'm a cold-hearted bastard for even thinking of this? My point exactly.)

The thing is, I wouldn't even mind the "drag me kicking and screaming into the night" philosophy except for the hypocrisy behind it. It's perfectly fine for people to spend society's money like water - we estimated that the state sunk close to $1 million on one patient - but as soon as you tell them that they will have to help foot the bill, it's, "where's the plug? Oh, never mind, I'll just cover his mouth with the pillow." Lesson: a person's resolve is inversely proportional to how much will come out of their wallet. And death is like winning the lottery - all sorts of people you never knew come crawling out of the woodwork. We had a guy who was neglected for years by his family - he was malnourished, had ulcers on his body, and was depressed because he was never visited by his family; but he approaches death and you have to deal with a weepy daughter who "could never live without my dear, dear father!" and demands you do everything for him or she will sue.

I apologize because I know this post is probably brutal and cold-hearted, but I tells it like I sees it. Which is what gets me in trouble all the time.

 

[freelancewriter]

This story (1 in 5 die in ICU) is starting to get picked up by more and more news outlets, with local touches added:
http://kdka.com/local/local_story_098093217.html
http://story.news.yahoo.com/news?tmpl=story&cid=571&ncid=751&e=1&u=/nm/20040415/hl_nm/us_icu_dc
http://seattlepi.nwsource.com/national/168335_icu09.html
http://www.eurekalert.org/pub_releases/2004-04/uopm-eol040604.php
etc.

The study cited is in the March 2004 issue of Critical Care Medicine.