Thursday, August 20, 2009

Palliative Care featured (again) in the New York Times

I recall someone saying that the New York Times has started to produce enough articles on end of life care to become a palliative care textbook. It is wonderful to see such high profile coverage of our field which is generally very complimentary. Just type in Pallimed and "New York Times" into Google and you will get a sense of how many times we have covered at least the big articles here.

Today's feature article (6 web pages as opposed to the usual 2) follows the palliative care team at Montefiore Medical Center and centers around a couple of patient stories. The story, "Breaking Bad News," is part of a year long series called "Months to Live" which seeks to "explore the promises and challenges of extending, or ending, the lives of very ill patients." The articles are on a monthly basis and the two previous stories are "Gently into the Night" and "Quest for a Miracle". (Did I use enough quotation marks? Or did I need more parentheses? Here is a semi-colon; just for kicks)

Obviously having a feature story on talking about end of life care is timely given the heated discussions about HR 3200. But in reading the article there were a few things I found concerning and maybe I am being overly critical. It was just after reading it, I wasn't running around to show the article around as a good representation of palliative medicine work.

So let's start out with the PROS (with a few editorial comments):

"Part psychoanalyst, part detective, Dr. O’Mahony had to listen to the cues and decide what to do next."
Excellent description of the searching and complex conversational skills good palliative care staff have.
"But Dr. O’Mahony does not press hard for a written advance directive,"
Important to recognize that palliative care staff go where the patient is at psychologically, philosophically.
"But before leaving, he made sure that she had a health care proxy — her husband — who would make decisions for her if she became incapacitated. He knew it would be harder to get one later."
While at the same time recognizing important opportunities exist to get crucial questions answered or tasks completed.
"For about an hour, Dr. O’Mahony asked open-ended questions, looking for clues as to how much she knew and how much she wanted to know."
Good palliative care takes time and active listening!
"A student named Paul (most asked to have their last names withheld for fear of harming their careers) told Ms. Telcher that her mammogram had revealed a “finding.”"
Choosing the right words is a skill learned with time, experience, and good mentoring.
"Two doctors on Dr. O’Mahony’s team listened quietly, and she seemed relieved just to be able to talk things through."
Listening is therapeutic. Write it down on your medical plan.
“Many clinicians don’t want to send the message that they’re giving up on their patients,” said Dr. David Goodman, a co-author of the Dartmouth Atlas. “They see palliative care as diminishing hope.”
A statement I can generally agree with BUT in publishing it does it also reinforce the false belief that palliative care is about 'giving up.'
"While there is nothing in the House bill to suggest that such panels would exist, the end-of-life language became so radioactive that several members of the Senate Finance Committee said they would not include it in their version of the bill."
Yes, please correct the misinformation! And realize misleading statements do have consequences.
"But some of these [palliative care cost savings] studies have been conducted by advocates,"
Good to fairly acknowledge a potential bias.
"“It’s just sort of letting them die completely naturally. It’s hard to explain to a lay person, because we know we need food and liquid to live. But we don’t need them to die. We’re just feeding whatever is killing them.”"
I feel sort of mixed about this one. This issue needs wider discussion, but in my experience the difficulty lies not in the explanation but in accepting emotionally what lack of feeding means.
"Asked how she deals with the death of her patients, Dr. Shaiova said, “I play the harmonium.”"
Yay self-care! Needs more press for people in tough occupations.
"She would return from the [radiation] treatments — administered every day for 29 days, her husband said — in a stupor."
I am not sure why radiation treatment side effects always seem to get downplayed, but they do. So it is nice to see some of the total impact addressed including the stamina/cognitive effects of radiation.
"“During these times when her thinking is impaired, you are her voice,” Dr. O’Mahony replied."
I really like this statement. I use variations on the theme many times when helping surrogates figure out how to make tough decisions.
"He had several conversations with her before she died, a luxury that other types of doctors might not have."
This is one thing that makes palliative medicine unique. "Luxury" is a very interesting choice to describe this. Does time=money?
"“Patients sometimes will be very explicit about wanting that information very, very clearly delivered,” he said. “Whereas other people don’t.”"
The simple act of listening to the needs of a patient goes a long way into personalizing treatment.

And here were some of the cons: (Disclaimer: I don't know the docs mentioned in this article and I realize some of their words are taken out of context. This is not a knock on their practice at all but maybe how the reporter portrayed them. I have had words misconstrued in reporting before which I think for our field will continue to be a frequent hazard given the nuances of our conversations.)
"[Palliative care] has also become a focus of attacks on plans to overhaul the nation’s medical system..."
Palliative care is under attack? Well not really. Maybe indirectly, but I have not yet heard hospice or palliative care besmirched. We need to be careful with words like this because this sentence effectively places a target on our field, which I feel has escaped harm thus far.
"They know who is more likely to suffer silently, and when is the best time to suggest a do-not-resuscitate order."
I have trouble with the wording of 'suggesting' a DNR order. I just don't think it fairly reflects how many palliative care teams approach DNRs. I would have preferred 'discuss' since it implies no agenda which reflects patient-centered care.
"A third of Medicare spending goes to patients with chronic illness in their last two years of life; the elderly, who receive much of this care, are a huge political constituency."
Are versions of this statement exhausting you? While a true statement, it starts to become a straw man fallacy regarding cutting costs. Good comfort care is not necessarily cheap and figuring out prospectively when the last two years of life are for chronic illness is extremely difficult given our lack of a Medical Prognostication Manhattan Project.
"Rather, Dr. O’Mahony and his colleagues were more subtle, cunning and caring than their own words sometimes suggested."
Oh please don't call palliative care doctors cunning. Skillful? Sure, sounds good. Wiley and deceptive? I'll pass.
"They are tour guides on the road to death, the equivalent of the ferryman in Greek myth who accompanied people across the river Styx to the underworld."
Ah mixed metaphors. Tour guides on the road to death (i.e before death) is much different than Charon (the name of the ferryman BTW) who guides the already dead. And besides palliative care is more than death & dying so please beware the pigeonhole. (But if you are reading this you probably know that already.)
"Dr. O’Mahony entered the field a decade ago, shaped by an almost messianic movement that began as a rebuke to traditional medicine but has become more and more integrated into routine hospital practice."
Huh? What? Messianic movement? You mean this has something to do with making sure Jesus is recognized as the messiah of Judiasm? Why did this get put into the article? Can someone explain this?
"His coolness is his armor. “I do not feel obligated to be sort of eternally involved with the experience of death,” Dr. O’Mahony said. “It’s not healthy to be there all the time.” But the danger is that “death gets to be banal,” he said. “Do you know that poem by Dylan Thomas?” Dr. O’Mahony asked with a faint smile. “After the first death, there is no other.”"
I have no problems with these statements in fact I agree with them. My problem is the poor follow-up and dropping of the subject of how to deal with high death acuity. Did the reporter have to include 'faint smile?' It leaves a lot open to interpretation which I don't feel is fair to Dr. O'Mahoney.

"But Dr. Nicholas Christakis...has found that doctors are generally bad at making prognoses." --(later in article)--“Doctors are the worst predictors,” she said after the session."
Now I adore Christakis' efforts and work. But this constant harping of poor prognostication by doctors based on anecdotal experience and a few research studies really undermines our field. EVERY medical decision is rooted in prognosis. And if we are so bad at it, why are we not paralyzed by our inadequacy. And if we are so bad where is the Medical Prognostication Manhattan Project.

"The better they know a patient, the worse they are at prognosticating, possibly, Dr. Christakis has theorized, because they view death as a personal failure."
I used to believe this but I think it is the rare doctor who sees death this way. It makes for a nice story but is this really the cause of poor prognostication or is the fact we are working with dynamic complex open systems of biological tissue (aka a human) a much larger part of the degree of difficulty? You can guess my answer.

"The bill would help validate the work of palliative care doctors..."
No! This bill does not validate my work. Not one bit. Feedback from families and patients like those found in the 177+ comments to this article validates my work.

"Palliative care still goes against the core beliefs of many doctors."
Hmmmm...do you like good symptom management? Yes. Is it important for patients to understand and be involved to their best ability in their own care? Yes. I hope these two aspects are core beliefs of every doctor because simply that is what palliative care is.

"The receiving hospital, she believed, was part of the conspiracy of denial, only too happy to get the payment for accepting the patient, who ended up dying before he could be evaluated."
We as a field have to be very careful about statements of the intent of other doctors to make money. I have heard other palliative care and hospice staff make these concerns and have had them myself. But without more proof, this is dynamite. The more likely explanation...tertiary hospitals need to be seen as gracious recipients and so they accept many even if there is not a large difference in care options. If they started saying no to another hospital more often, they might not see any more patients.

""“I can’t give a definite response in terms of the number of days or weeks,”
Dr. O’Mahony said. Mr. Migliore said another doctor at the hospital had estimated four to six months." While the context and supporting statements from Dr. O'Mahoney may have been edited, I think the article shortsights a palliative care teams ability to give some prognostic estimates to help with practical issues surrounding caregiving, family obligations, and time for the patient to plan appropriately. This is one of the things we get commended for the most from families and patients.

"Dr. O’Mahony has not spoken to Mr. Migliore since his wife died, and he does not expect to."
Wit a high number of deaths for hospices and palliative care teams we should not expect to stay in touch with everyone, but the way the reporter worded it makes it sound like abandonment which was likely not the intent of Dr. O'Mahoney to convey. I don't expect this either, but the support for families often continues through grief and bereavement services.

"Once the ferryman has delivered his patients across the river, he rarely looks back."
Oh stop it with the metaphors already. It was bad to begin with.

So was I way off base or did you feel the same way?