Pregnancy and Palliative Care

If one was to talk about fields that no one would think would be related in medicine, obstetrics and palliative care seem to be worlds apart, but two recent articles make it clear these fields are not that far apart. In the first, an editorial from the Journal of the American Board of Family Practice, titled "Pregnancy care: an apprenticeship for Palliative Care?" (free PDF) the author defines how the beginning of life and end of life require similar approaches from the medical field.

When I read the title, I immediately recalled the wise words of a resident who rotated with me at Kansas City Hospice about how the unpredictability of death mirrors the unpredictability of when someone will give birth. That resident was David Wensel, DO, and he was from Mason City, Iowa, and I thought someone stole his idea, but then when I saw the author was his Palliative Medicine Fellowship Director David Clark, I remembered that Wensel told me he heard that from Clark. Anyway enough about my six degrees of separation.

Dr. Clark describes an obstetrics patient who helped him understand the cooperation, compromise, clear communication and respect that would later serve him well in his palliative care work. A table defines the salient teaching points about good doctor-patient relations in both fields and is helpful for mentors in obstetrics or palliative care. This table could also extend to all medicine specialties to some degree which is helpful to define a 'palliative care' approach to all patients, something I try to discuss with medical students who may never go into a field where they may see a dying patient.

The second article from MSNBC tells the story of the growth in perinatal hospices for parents who know before birth that their child has a terminal condition. The growth in perinatal hospices mirrors the rise in genetic screening and the dreaded anticipation with the knowledge of likely death soon after birth. The toll this can take on a family is enormous and requires a high degree of flexibility and sensitivity on the part of hospital and perinatal hospice staff. The article covers perinatal hospice very well and tells a wonderful story of how adversity can bring out the best in people. A great quote from the article:

“Don’t assume we’re Luddites or religious fanatics,” Kuebelbeck says. “Don’t assume we’re saints. We’re just parents doing the best we can.”

Below is a 4 minute video clip (from the MSNBC site) of the family whose story is told in the article. The mother sums it up at the end very well:

"There was so much support and love flowing around it all, that it was a beautiful experience I would never wish upon anyone else."

Warning you may likely shed a few tears while watching this.



I am fortunate to have a perinatal hospice with my organization and the staff does wonderful and amazing work. If you have not had the chance to work with a perinatal hospice and you are in palliative medicine, reach out and see if you can help some programs. While the work can obviously be emotionally difficult it can be extremely rewarding.

• The Gazette (Montreal, Canada) has a fascinating historical look at the first two opium wars and a legal case to rival any current legal drama on television involving morphine and atropine. Great story for attendings who need to wax eloquently on rounds.
• Marc Dingman at Neuroscientifically Challenged (a blog) gives us a quick history of how medicine and science have looked at dopamine.
• Leftover morphine and hastened death are examined in an opinion piece from the Quad City Times. (Hello again Iowa!) The piece is written from someone's personal experience with a friend in hospice who had briefly talked about hastening her death. It appears the situation was averted with good symptom control and support, but the writer still appears to have a crisis of conscience. The comments section makes for good reading and understanding of how many different people view this difficult situation.

References:
Clark WD. Pregnancy care: an apprenticeship for palliative care? J Am Board Fam Med. 2008 Jan-Feb;21(1):63-5. DOI: 10.3122/jabfm.2008.01.070099