Monday, January 25, 2010

Los Angeles Times Focuses on End-of-Life Care

The Los Angeles Times is featuring a few articles on hospice and end-of-life care. First,
"People may think that the more money spent on their healthcare, the better care and quality of life purchased. At the end of life, it doesn't work that way," says Holly G. Prigerson, director of the Center for Psycho-oncology and Palliative Care Research at the Dana-Farber Cancer Institute at Harvard Medical School. She was one of the authors on an end-of-life care study published last year in the Archives of Internal Medicine. "In fact, we found the opposite to be true. We found that most of the costs of end-of-life care pay for burdensome, non-curative care that offers no substantial survival advantage."

That study showed that cancer patients who planned in advance with their doctors about end-of-life treatment had much lower healthcare costs in their final week of life than those who didn't. What's more, the higher the cost of medical care, they found, the worse the patient's quality of life was in the final week of life.
Christie Aschwanden offers a basic review of hospice, including who is eligible and what to expect. (For more information on hospice, see HFA's What is Hospice? section.)

When and how to have the discussion: Family members and terminally ill patients often struggle to initiate discussions about death, and this can result in a conspiracy of silence that can delay hospice care, Whitney says. "Very often the patient says to me, 'I know I'm dying, but please don't tell my wife.' And then I'll talk to the wife and she'll say, 'I know my husband is dying, but please don't tell him.' "

Because doctors too may be reluctant to suggest hospice, it's often up to the patient or family to ask. If needed, hospice staff can call the doctor to help initiate the discussion.
Today, discusses a study from the journal Cancer that we posted earlier this month.
Here's a closer look at why end-of-life discussions are important.

If done sensitively and as part of ongoing medical care, discussing whether to resuscitate, when to seek hospice care and where patients want to spend the last days of their lives can actually empower patients, rather than making patients lose hope, say Keating and other palliative care experts. Instead, the talks help patients gain some control over treatment and over the final stage of their lives.

"My own view about this is that the whole approach to dying is really an approach to living," says Dr. Katherine Kahn, a UCLA physician and co-author of the new study. "The more we can make these discussions about end of life part of a larger set of discussions with patients about how they approach medical care and how they approach life, the better we can honor their medical wishes when it comes time."

To do this, patients and doctors need to accept the facts, says Dr. Michael Levy, an oncologist at Fox Chase Cancer Center in Philadelphia. He chaired the panel that crafted the cancer network guidelines.

Only 15% of patients with Stage 4 cancer have a viable chance at a cure, he says, and even in those patients, only 50% are cured. "That means that 92.5% of patients with advanced disease will die of their cancer," Levy says. "So you've got to just talk about it."
In the column, In Practice, Mark Morocco, an associate professor and associate residency director of emergency medicine at UCLA Medical Center, writes about his difficulty discussing end-of-life care with a particular patient when he was a medical student.


I was the "sub-intern" -- a few months from graduation -- so when Mr. Martinez exasperated the last of the "real" doctors, they passed the hot potato, and the responsibility for his end-of-life care, to me. With the latest academic ideas on hospice care still fresh in my mind, I knew exactly what to do. I would control his pain aggressively and arrange for care in some place where he could "die with dignity." If only I could get him on board with this plan, my job would be easy.

Obvious Lesson No. 1 in medical school, however, is that there is nothing easy about "treating" death and nothing simple about making plans for it. Armed with miracle machines and genetically built drugs, doctors promptly forget this lesson in our focus to save our patients or to at least let them live another day. Yet death waits for all of us, and, like Mr. Martinez, we usually just don't want to talk about it. "What's to talk about?" he'd yell at me. "Go away!"