Comment: What should medicine do when it can’t save your life?
Dr Michael Minton comments on an article in The New Yorker by Dr Atul Gawande:
“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.”
LETTING GO: What should medicine do when it can’t save your life?
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.
Read the full article at The New Yorker…
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.”
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Dr Atul Gawande
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”
In India where most doctors especially in the government hospitals are already over-burdened, it might be impractical and unfair to expect doctors to spend a lot of time counselling patients about the best options in delicate and sensitive situations like terminal or fatal illness. It might be more realistic to have a psychologist with additional training in palliative care to guide the patient and family about the best options available in such situations.
Now that the Kerala University Of Health & Allied Sciences is proposing to set up a School of Health Policy & Planning, organisations like Pallium India could initiate dialogue with the University in its task of creating an academic platform to deal with palliative care issues.Those who graduate from such a school would be the future contributors to the health care policies of the government. They could get the government to play a pro-active role in creating awareness among the general public about the importance of taking end-of-life decisions before the eventuality arises.
Death is a subject most people evade thinking or talking about. Earlier, people felt inhibited talking about contraceptives and sexual health. But, with the government’s intervention using media to bring out these closeted issues into the public domain, more and more people are being educated and enlightened.Just as donating one’s organs after death is also being promoted in spite of it being a highly sensitive and taboo issue in our cultural context, public thinking should be directed to facing this inevitable issue: how far will any one go to prolong life when there is no real hope of cure or recovery or living a productive and dignified life?
The medico-legal issues involved in the implementation of such decisions should also be taken care of. Hospitals should be equipped with trained personnel who can guide patients and their families in taking the right decision.
In a country like ours where the majority of the population is poor and illiterate, it is very essential to educate them on these issues so that they do not fritter away their meagre resources on needless and futile interventions that will only buy the patient a few more agonising hours.Of course, every life is equally valuable and precious, so the basic premise holds good for the affluent too, only that they can afford it and let us admit it, it is an unfair world no matter what is the politically correct thing to say. Medical insurance premiums and the cost of certain interventions should be made prohibitively expensive to deter people from resorting to them.