Comment: What should medicine do when it can’t save your life?
“This is a very insightful article by an American surgeon who as a result of his concerns about how modern medicine can poorly serve the terminally ill patient, takes a journey of discovery and researches what the palliative care approach has to offer his patients.”
by Atul Gawande, The New Yorker – 2/8/10
Sara Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die. It started with a cough and a pain in her back. Then a chest X-ray showed that her left lung had collapsed, and her chest was filled with fluid. A sample of the fluid was drawn off with a long needle and sent for testing. Instead of an infection, as everyone had expected, it was lung cancer, and it had already spread to the lining of her chest. Her pregnancy was thirty-nine weeks along, and the obstetrician who had ordered the test broke the news to her as she sat with her husband and her parents. The obstetrician didn’t get into the prognosis—she would bring in an oncologist for that—but Sara was stunned. Her mother, who had lost her best friend to lung cancer, began crying.
The doctors wanted to start treatment right away, and that meant inducing labor to get the baby out. For the moment, though, Sara and her husband, Rich, sat by themselves on a quiet terrace off the labor floor. It was a warm Monday in June, 2007. She took Rich’s hands, and they tried to absorb what they had heard. Monopoli was thirty-four. She had never smoked, or lived with anyone who had. She exercised. She ate well. The diagnosis was bewildering. “This is going to be O.K.,” Rich told her. “We’re going to work through this. It’s going to be hard, yes. But we’ll figure it out. We can find the right treatment.” For the moment, though, they had a baby to think about.
Dr Minton continues…
“He learns that patients who have the opportunity to receive palliative care alongside their anticancer treatment fared better than those who had treatment (usually chemotherapy) alone. The former patients used hospital and intensive care (ICU) less. They were more likely to achieve their wishes which often included being able to die at home. Their carers at 6 months after the death were better emotionally adjusted. The surgeon was also surprised to learn that in some groups of patients (eg cancer of lung and pancreas) even lived longer than those receiving palliative chemotherapy. He had previously believed that patients choosing palliative care always died sooner.
He came to appreciate that the majority of people are prepared to discuss their wishes for the future and write advance directives. In particular he was amazed to realise that carefully conducted consultations can help patients, families, and their doctors identify the expectations and anxieties which enable more patient orientated care to be given. He concludes that doctors must be prepared to discuss end of life issues and help patients plan for their future even while pursuing further treatment.
He highlights a hospice doctor who reminds him that effective communication is an acquired skill and requires no less experience than performing a surgical operation. The key features of an interview are to allow and facilitate the patient to explore their understanding of the illness and prognosis, including anxieties about the future. This requires the doctor to actively listen and acknowledge these concerns without necessarily trying to provide all the answers.
This is an honest and revealing article of a surgeon who stops to think about his dying patients and learns what palliative care can offer his patients. I urge you to encourage any sceptical colleagues to read the article.”
Dr Gawande has written some eye-opening articles on the US healthcare system. Read them at the The New Yorker website and many others on Gawande.com – including the commencement speech to graduates at the Stanford School of Medicine: “The Velluvial Matrix”