Tuesday, June 6, 2006

Chemo, ICU, ER visits at the end of life and follow-up

The AP released an article that made the front page of the Kansas City Star this past weekend highlighting a study from ASCO. The data showed the number of ER visits, ICU stays and chemo use in the last few weeks of life had all increased throughout the 90's. Interestingly in the same article they mention another study that shows not enough patients with cancer get offered chemotherapy. Unfortunately the article did not have the space/time to go into all the complex details as to why this is, so I am afraid the message comes out confusing for those who read the whole article. Kind of like one of those coffee/wine/fat/carbs/mammograms are bad for you...wait...wait...no they are good for you scenarios we see all too often in media reporting on medical matters.

I am just glad to see that these topics are being addressed at ASCO.

Here is a follow-up on my concern about the Wall Street Journal article on the cost-savings argument for palliative care teams being implemented...

My letter to the editor did not get published. Oh well. But if you are going to get published you have to expect to get denied. That wisdom was shared with me by Ira Byock, MD, who has published a few things, and as he shared been denied a few times.

But the nice thing about having a blog (Thanks Drew!) is that you can post your denial letters. Happy reading!

RE: Care Varies Widely at Top Medical Centers - May 16

The selected quote from the NYU Medical Center Chief Medical Officer, Dr. Cohen, regarding the utility of palliative care services as "effective in limiting overuse of resources" was grossly misrepresentative of many palliative care teams in hospitals across the country. Palliative care teams have the primary goal of supporting and comforting the patient/family unit during the course of a hospitalization, especially when the patient may be facing a life-limiting illness. Often times this occurs by slowing the overwhelming clinical inertia of more diagnostic tests and therapeutic options to allow the patient and family time to ask questions and understand their diagnosis and prognosis. After sitting with and listening to patients and families, sometimes for hours over days, the goals of care may be adjusted to reflect the patient's wishes, which may be to limit aggressive measures.

Dr. Cohen's statement reflects the hurdles palliative care teams have to overcome to justify their services to hospitals. The time and cost of having a multi-disciplinary palliative care team is high, and reimbursement for talking and listening to patients is miniscule compared to medical procedures. Palliative care teams will hardly ever cover the costs, so hospitals should employ palliative care teams primarily for the quality service and symptom control given to patients. If palliative care teams are to retain any trust with the community, any cost-savings from a change from curative to palliative should merely be viewed as an unintended benefit and not a mandate from the hospital.

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