Monday, December 21, 2009

The Breadth of Hope, Selling Hope, and More on Quelling Thanatophobia

The holidays are upon us, a new year is approaching, and hope abounds. Three prominent articles touch on the topic of hope in patients with life threatening illnesses.

Pediatric palliative care physician Dr. Chris Feudtner from the Children's Hospital of Philadelphia discusses the breadth of hope in pediatric patients and their families in his recent NEJM perspective article. The essay speaks for itself but here's a succinct passage that I especially appreciated:

"...when clinicians discuss the prospect of delivering bad news to patients or their families, we often speak imperatively about not "taking away" or "killing" or "destroying" their hope. Yet if hope writ large is in fact a collection of smaller hopes, to which of the various possible hopes does the imperative refer? Usually, the focus of paternalistic concern is on the distinct hopes of cure or long-term survival, which are exactly the types of hope that are most threatened by bad news. Indeed, such news often elicits feelings of intense sadness or anger in patients and families. But as countless patients and parents have taught me, although these feelings may signify the receding of a particular hope, other hopes remain or emerge: the process of hoping endures."
NEJM followed it up this week with a perspective piece by oncologist Dr. Benjamen Corn who discusses the relationship between thanatophobia and health care reform (edit: already commented on by Christian a few days ago, too, but I mention again briefly as it relates to hope).

As Christian mentioned, Corn calls for "conversations led by a team consisting of patient advocates (e.g. chaplains) and medical experts espousing countervailing views regarding the use of resources at life's end." I, too, prefer a more oblique view regarding resource utilization near life's end- while I think it's fair to say that most palliative care practitioners appropriately have a view that wasteful spending exists, this view cannot be central to the practice of palliative care for individual patients. The requisite trust for end-of-life dialogue doesn't spring forth from an attitude of rationing. Rather, the fertile ground for trust comes from attention to the whole person, the person's suffering, and identification of the breadth of hope.

But the hope for a long life remains dominant on the landscape of hope for almost all of us, and cancer centers throughout the country (and hospitals in general) capitalize on this hope. NYT continues their series "Forty Years' War" with a piece highlighting some of the disingenuous cancer center advertisements of recent times. While the Food and Drug Administration tightly (relatively speaking) regulates pharma advertisements for individual drugs, the Federal Trade Commission regulates ads for nonprofit medical centers, and the regulations are much more permissive. The common theme of many of the ads is that if you don't come to Med Center X, you'll miss your opportunity to be cured.
"But marketing executives defend their approach, saying cancer treatment ads tend to play more heavily on emotion than on medical statistics because the ads are not intended to inform people who already have the disease. They are meant to make an impression on future patients, who may decide on treatments years after they have seen an ad, or to sway influential people who might advise a future patient. “This isn’t retail advertising,” said Ellis Verdi, president of the DeVito/Verdi Agency in Manhattan. The agency produced the Mount Sinai ad, which ran in The New York Times, and has created cancer ads for other hospital clients. “This is reputation advertising,” Mr. Verdi said. “There is a very big difference.”
Indeed. It's not just the reputation of the cancer centers that is being advertised, but also the reputation of every hospital. If you haven't found the cure at your local hospital (even if it's a cancer center that routinely conducts clinical trials), then it must not be good enough!

Advertising for palliative care services at an individual institution already trying to "sell hope for a cure" becomes tricky in this environment because the message is contradictory. One unspoken message behind the "sell hope for a cure" ads is "we will not only cure your cancer so that you can avoid death, but we'll also make it so it's a non-issue in your life so that you can return to the way things were before. It'll kind of be like getting your car's air conditioner recharged." Why would you need palliative care in that circumstance? A good example is the Mount Sinai radio ad that you can hear in the left sidebar of the article.

Obviously there are many people more savvy than me thinking about how to "change the culture" to make palliative care the norm, but the concept of reputation advertising is relevant to our field and it seems to make sense that this would be a nationwide endeavor rather than institution specific. In other words, instead of trying to convince a patient with metastatic colon cancer and his oncologist in Springfield, Anywhere that he should consider seeing a palliative care service at Springfield General, the advertising message should be aimed at all the healthy people out there everywhere who occasionally think of what it would be like to have a life-limiting illness.* Expectations should be created that counter-balance the message of "we'll cure you and you'll be fine" including:
  1. We'll help you find the breadth of hope (and there's room to include the hope for as long of a life as possible). Improved quality of life is a big part of this but it's not improving QOL for it's own sake but for the sake of hope.
  2. The mere possibility of death strikes fear in the heart but the act of preparing for it can reduce that fear (and, in fact, the preparation can be a source of hope).
  3. Your loved ones are very important to you and therefore, to us as well. (Sounds like an ad for life-insurance, I know...)
In other words, we're the hope-brokers. I'm thinking of an ad where the patient has just returned from a dreadful trip to Mecca Medical Center only to find that nothing could be done there. After returning home, he discovers the local palliative care program and WOW...he wishes the service would have been known to him on the day of diagnosis! There might be an ad out there that already does this well. I want to see it during the Superbowl amidst all the ads hawking products aimed at "palliating" our human impermanence.

The NYT article describes the efforts to put limits on the type of advertising described. For a colorful description of the history of advertising in medicine, I'd recommend this article.

And for more Pallimed discourse on the topic of hope, see here.

*Individual palliative care teams need to take a different advertising approach aimed at referring providers locally, but certainly providers aren't immune to nationwide advertising schemes. I'd be curious to know how Lipitor advertisements during major sporting events influence physician practice (besides the effect of more patients "asking their doctor about Lipitor.") Of course, when consumer demand for Lipitor goes up, Pfizer can just crank up the manufacturing's a separate dilemma for the field of palliative care, but might be a good one.

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