Understanding palliative care

Excerpted from "Teaching doctors when to stop treatment," commentary by Diane E. Meier and Health Affairs in The Washington Post. May 19, 2014 — For years I had tried to understand why so many of my colleagues persisted in ordering tests, procedures and treatments that seemed to provide no benefit to patients and even risked harming them. I didn’t buy the popular and cynical explanation: Physicians do this for the money. It fails to acknowledge the care and commitment that these same physicians demonstrate toward their patients.

Patients and families often assume their doctors are trained and knowledgeable about end of life. Patients and families also assume that doctors will tell them when time is running out, what to expect and how best to navigate these unknown and frightening waters. But many doctors don’t do these things. Most, in fact, have no training in this. Medical school and residency have traditionally provided little or no instruction on how to continue to care for patients when treatments no longer work.

Physicians are trained to make diagnoses and to treat disease. Untrained in skills such as pain and symptom management, communication about what to expect in the future and achievable goals for care, physicians do what we have been trained to do: Order more tests, more procedures, more treatments, even when these things no longer help. Even when they no longer make sense.

So how do we fix this? To change behavior, we must change the education and training of young physicians and the professional and clinical culture in which they practice. New doctors should learn about the management of symptoms such as pain, shortness of breath, fatigue and depression, with intensive training on doctor-patient communication: how to relay bad news, how to stand with patients and their families until death and how to help patients and families make the best use of their remaining time together.

Commentary

CMDA Past President and Oncologist Al Weir, MD: “The author describes an unusual case history to suggest two important questions: As doctors, do we know how to resist making life longer when it’s no longer likely and instead focus profoundly on making life the best it can be? Do we know how to ask others to help us in this task?

“Sometimes we, and our patients, may cling to hopes that are no longer realistic. Instead, we should be open and honest and help our patients navigate their way through a new truth of life. Such a shift in effort does not come naturally for most of us; time, skills and compassion are required. Palliative care teams are often the best way to supplement the capabilities and time we may be lacking.

“Even experienced doctors should seek to sharpen their skills and become mentors for our next generation, so that these younger doctors may be more adept at compassionate end of life care than we have been.

“Today was an unusual day for me in which I had the privilege of sharing bad news and redirecting life goals with three patients, while a medical student leaned silently against the exam room wall. After the last such conversation I probably surprised him by saying, “You know, though the circumstances are horrible, I actually like having these conversations. In such moments, I can be the one who shares this awful truth with kindness and love. I trust myself to do this better than others, because I really care for them. I did the work to help them live longer. Now things have changed and I can do the work to help them live better.”

Resources
End of Life Care Resources
Medical Futility Ethics Statement
When Your Doctor Has Bad News by Al Weir, MD

Are you interested in learning more about bioethics? Join us in Deerfield, Illinois on June 19-21, 2014 at The Center for Bioethics & Human Dignity’s 21st Annual Summer Conference – Bioethics in Transition. With a variety of workshops and courses, you will examine the rapid advances in medicine, science and technology that continue to reshape the scope and landscape of bioethics.