Letting Go. What should medicine do when it can't save your life?

[HickoryTree]

This article looks at the difficulties related to the choice of hospice.

http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=all

[lesrn2005]

Extremely sad stories.

[tewdles, RN]

I find that too many physicians have a difficult time speaking to patients about death as an outcome of the disease process. And, too many nurses who work with those physicians do not feel that it is their domain to speak with patients about this topic.

So, many end stage cardiac, pulmonary and renal patients continue with aggressive intervention at the expense of their dignity and quality of life. In my geographic area our average length of stay for hospice is less than 7 days...LESS THAN 7 DAYS. That means that these very sick people come to us over hydrated, in pain, short of breath, nauseated, and generally on death's doorstep...they are usually elderly and have put their complete trust in the guidance of their MD. Unfortunately, their physicians have guided them repeatedly into curative rather than palliative pathways, often without really speaking with the patient about other options.

For the record, a passing comment or polite "mention" of the word does not qualify as a discussion.

I experienced this with my mother who was dying from COPD (in a distant state). Her physician (who was also a personal friend and a coworker of hers for a number of years) was not comfortable with the transition of his patients to palliative pathways of care...and so it was neglected. I finally had to intervene and arrange for my mother's admission into hospice myself and then had to request that her MD please sign the certificate of terminal illness when he balked. I was terribly disappointed that he had not spoken earnestly to my mother about hospice since he and I had discussed my mother's prognosis during her last hospitalization 3 months before.

My mother died less than 4 weeks later. How sad to me that had her physician recommended hospice months earlier she would have been spared considerable suffering.

This article is on target and I thank you for sharing it. I will be sharing it as well...

[leslie :-D]

this article confirmed what i believe, most hospice nurses already know...

that (too) many doctors totally lack any ability in discussing eol and its surrounding issues.

aeb the article, many would prefer to try plan d, e, and f, after a, b and c have failed.

many suffer a tremendous 'knowledge deficit' as to what entails a 'good' death.

compound this with the pt's primal instinct to live, it's no wonder that hospice is so profoundly under utilized.

i see only one solution to this:

1. ALL med students should have eol/futility of treatment incorporated into their academic curriculum.

i'm not talking about a 4 week certification type program, but discussion should be ongoing throughout med school.

when they're learning respiratory, talk about how lung ca, end-stage lung disease, etc, impacts one's life, with emphasis on choices these pts have.

when they're learning gi, talk about how pancreatic/colon/stomach ca's and standard txs, affect one's life, and again, with emphasis on choices.

there are ways to keep these issues going, IF it is ever acknowledged that being learned in life AND death, is the only way to wholly treat a pt.

med students need to be educated in the difference betw life and mere existence.

once these folks become physicians, they will be comfortable in addressing what is best for the pt...

since we know that invasive and dangerous txs, are not always in the pt's best interests.

in the meantime, i see little changing. :-(

if medicine cannot cure, it can certainly keep our sick folks comfortable.

now it's just a matter of some dr's recognizing that dying is not about their discomfort, but their pt's.

and if it's just a matter of one, swift dopeslap, i will happily volunteer.

leslie

[AtlantaRN, RN]

Most physicians look at death as personal failure. Somehow if they just would have managed a patients care, they would have been successful at preserving life. This just isn't so. We all have our race to run. I agree physicans curriculum should include end of life care.

[netglow, ASN, RN]

I so agree with this. Someone I've known for years recently died. Found out about repeated procedures from specialties (you all know who the guilty parties are here). Can't go into detail, but I found myself turning red with anger at this as it was too close to home. Had to struggle to keep my feelings in check at the funeral.

I spent a lot of time in ICU as a student. TOO MANY situations like this. To look into their eyes, and think, wow your gonna go though hell these last few days... wanting to say you were sorry because you know what's gonna happen now, having come out of interdisciplinary report and finding the family has just revoked DNR, and it looks like nobody took the time to really lay it out for them and the patient truly believes we won't make him die a horrible death. The trust the older generation has in us. Makes me sick.

[rn/writer, RN]

Too many docs take a patient's death personally. They feel like they're hanging in there and fighting the good fight if they refuse to recognize the inevitable. AND (and this is a big one) they don't want to be the one who causes the patient to "give up."

We need to equip docs with ways to connect on end of life issues and teach them ways to ask questions and offer options the gently lead in the direction of palliative care, hospice, and comfort measures. I do believe many of them know the score, but they don't know how to broach the topic in a way that seems appropriate without feeling like they're closing the door on the patient.

Leslie's right in saying this needs to be interwoven through med school and residency. Learning the fine art of helping the patient to have a good death requires more than attending a two-day seminar or reading a book (although those choices are a good place to start).

One other thing. A doc's training years are time when they feel the kiss of immortality. Saving lives (or even removing appendixes) is heady stuff. They're young and powerful and death is an abstract concept most frequently viewed as the enemy.

At some point, though, hospitals or other facilities where docs are on staff need to work with these vibrant and shiny beings to help them come to terms with their own mortality. The inability to face the fact of one's own eventual demise plays a big role in this discussion. Docs who have a strong spiritual belief and a sense of the immortality of the soul are more likely to be able to enter into this arena and connect with patients and families in their time of need. But even those who don't need to stretch a little and meet the dying where they are.