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Monday, June 1, 2015

Double Standards in Palliative Care Delivery

by Liam Farrell

Some years ago, on an inpatient hospice locum, where the majority of the hospice residents had cancer, I made a point of visiting the day room as often as I could. It was a source of wonder; whenever I looked in it would be humming with activity. In one corner, a sing-song would be in session, with a volunteer accompanying on piano; in another corner, set up as a little coffee shop, there were animated discussions going on at every table. Outside, the minibus, driven by another volunteer, was drawing up, and some residents burst in the door full of news about their guided trip around the Botanic Gardens. It was a place where death was not considered an enemy.

The locum post also included home visits, and during one of these I attended a patient in a nursing home for the elderly. After the consultation, on the way out, I passed the day room. It was huge, gloomy, and cavernous. The floor was covered with a grubby stained carpet, and the curtains were partly drawn even though it was a dull cloudy day and dark enough outside. A television was blaring; a children's cartoon was on. The old people were lined against the wall; some were rambling and whispering to themselves, others were dribbling, most were just staring into space. An old man sitting near the door pawed at me, and I recoiled involuntarily and fled. There was just too much grief, too much misery to cope with; it was a place where death would have been a real friend. As with the Struldbruggs in Gulliver's Travels, there can be no fear of death when we see the real horrors of eternal life.

But why? Why is there such a gulf in the level of care? Both sets of patients are dying and both are surely equally deserving.

There are, however, some significant differences. The people in one group are younger and are able to communicate their symptoms better, and they have more predictable and shorter prognoses. For every patient dying with cancer, a family doctor will have three or four dying with one of the degenerative diseases of the elderly. If a patient with senile dementia is in severe chronic pain, are any of us going to have the time to visit them regularly during the day and follow them up regularly during the following weeks and years?

As W.B. Yeats said, “Too long a sacrifice can make a stone of the heart;” and if it’s tough for us, consider the 24/7 burden carried by the carers, with no end in sight.

Patients with cancer are different and, dare I say it, easier to look after; it's like getting on a train a few stops from the station. We know that, however onerous the commitment, it won't last for ever. So lots of other passengers jump aboard: distant relatives, neighbours, specialist nurses, hospice doctors, social workers, chaplains. And when the train pulls into the station—bang!—we all jump off in a huge blast of endorphins.

Do-gooders? As John Wayne said, “We're doing good for ourselves.”

Please come join Dr. Liam Farrell as he hosts #hpm chat this Wednesday night. Details below.

Related Resources:
Irish Times Article June, 2015: Elderly care home patients given ‘chemical cosh’ drugs
Journal of General Internal Medicine Feb. 2015: Hospice use among nursing home and non-nursing home patients
New England Journal of Medicine, May 2015: Changes in Medicare costs with the growth of hospice care in nursing homes

Dr Liam Farrell (@drlfarrell) has been a columnist for many years, for the BMJ and Lancet among others. He was a family doctor for 20 years in Crossmaglen, Ireland, and is a former tutor in palliative care. Follow his Facebook page.

What: #hpm chat on Twitter
When: Wed 06/03/2015 - 9p ET/ 6p PT
Host: Liam Farrell  @drlfarrell
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