When counseling patients and families about end-of-life care, I try to focus on a simple, clear standard. Knowing that events are overwhelming and complex, I say, “Look at each treatment, each action and each moment and ask; How does it improve quality of life?” My goal is to reduce the choices during a chaotic time of life to the simple goal of comfort.
For example, most families are very concerned about …
The role of chemotherapy in palliative care
Not long ago a woman in my community, who was a patient of an esteemed local oncologist, died. Let us call her “Beverly” and let us say she died of “breast cancer.” I am familiar with the details of the case because one of my partners saw her in consult, but HIPAA and common courtesy forbid me to be any more transparent. Beverly was very popular in our town and …
Doctors often don’t have the time to address social slander
One of the spinoffs of being an oncologist is that you do not to take the world for granted. Each morning, I walk around the yard and smell the morning breeze. I am thankful for my children, my wife and my own health. I am thrilled, if occasionally skeptical, to have the opportunity to pay taxes in a country that I love. So, who would believe I would take our …
Why I will never take EMRs for granted again
10:11am Tuesday, June 5, 2006: This was the moment Marge was told the mammogram showed a mass, which was probably breast cancer. “But, don’t worry, the tumor is very small and with surgery and radiation, you will be fine.”
1:55pm Wednesday, March 25, 2009: This was the moment Marge was told that the breast cancer had spread to her ribs. “But, don’t worry, the tumors are small, and with hormones, you …
When does false hope become malpractice?
One of the most satisfying sports is to make ourselves feel better by degrading another. What better way to make up for our own inadequacy, then to shove someone else’s face in theirs? We see this at work, in our families, in politics and in almost every type of social interaction. Nonetheless, it is particularly painful and tragic when we project our own fear and frailty onto someone that is …
Sometimes we give pain instead of hope
I have outstanding, compassionate and dedicated partners; rarely goes by a day that they fail to teach me by their intelligence and example. Nonetheless, yesterday, in the middle of 30+ patient office hours, one of them said, “You know there are times when I just can’t stand to listen to another complaint.” He took a deep breath, straightened his coat, and opened the exam room door and, smiling, greeted the …
The difference between playing doctor and being a doctor
It occurs to me that I talk to my patients more about death and dying, than about sex. It is not that I lack interest or an appreciation of the importance of intimacy, but like most physicians I fall into the trap of fighting the dread disease, instead of focusing on the wonders and power of wellness. Still, we do not rise each morning planning for our demise, rather we …
The importance of sex in the midst of a cancer diagnosis
When a patient leaves you for another physician, they simply cancel their appointments. You might get a message that says they are moving on and, two months later, you get a follow up letter from the new doctor.
However, Sam was unusual. He came in to tell me that because of my mistakes, his wife was transferring her care. What made our confrontation remarkable was that Sam was wrong.
I had recommended that …
Getting the medicine right, but failing in the art
It is in our nature to lie. Falsehood is one of the most creative things we do and the most remarkable of the human arts. We construct castles from ether and support their ephemeral walls on a foundation of accepted truths, which themselves are wisps of previous lies. The more we live within lies, the greater the challenge and more the harm. We pay a heavy price for fabrication. What happens …
What happens to us when we lie about dying?
New Jersey is considering following four other states in legalizing physician-assisted suicide. The Death with Dignity Act would allow people with less than six months to live to receive a prescription for a fatal cocktail and then to commit suicide at the time of their choosing in the privacy of home. Recently, I had the opportunity to participate in a debate on the merits of the proposed law. While I oppose this …
An argument against physician-assisted suicide
After you finish medical school classes, the night before graduation, they take you to a dark, quiet room. There, among leather bound tomes 300 years old, diseased skeleton trophies swinging behind glass, as you sip 50-year-old port in ancient crystal, they tell you the secrets.
This is the wisdom passed not in lectures, rounds or at the operating table; it is the hallowed legacy of thousands of healers over the millennia; …
When treating male patients, watch the wife
One of the first things I teach medical students is to be aware that they have arrived in a bizarre land. The strange things they see, the disturbed experiences they have, the weird stories they hear, are like noting else in life. I advise students to stay in touch with their feelings, to note what shocks, frightens, or embarrasses them. Remember those emotions now, because as doctors learn their craft …
Life for patients and their families is so much more than data
Recently I met the husband of a patient with a diagnosis of advanced lung cancer. Even though she was young and had been healthy, the disease spread to her bones. I outlined treatment for this incurable illness: choices, goals and side effects. This was a very tough meeting, because by the end we had to discuss time as measured by dollars.
The particular challenge was that this family had health insurance …
Money driven care punishes both the rich and poor
You are taking care of a patient with metastatic pancreatic cancer. The disease has spread, surgery is not an option and second line chemotherapy has failed. He is in pain, but is poorly compliant with narcotic directions. He keeps falling down the stairs. His wife cries all the time. The family is desperate for help. The patient is in the office with loved ones, looking for guidance.
“What do we do …
Recently, I continued my crusade to make end-of-life care a basic skill, as I gave the “Introduction to Dying” lecture to third year medical students, for the twentieth time. For me it is not just about pain control, family meetings and hospice care, but rather convincing physicians that they must change the medicine practiced for the last 100 years. That medicine says that a doctor can fight all disease, give any treatment, …
End of life care is a core part of medicine
I do not argue with my patients. Rather, I teach, outline options and explain my point of view, as each person must choose their path. However, the other day, Audrey and I got in a tiff when she was in the office to discuss her breast cancer. We had an enthusiastic discussion not of chemotherapy, x-rays or surgical options. Nope, we disagreed about what is wrong with healthcare.
It seems to …
Our dysfunctional system: Both doctors and patients are at fault
Not long from now, the last cancer will be defeated, and even today most with the dread disease survive. However, many still fall. This leaves us with one of the toughest questions of life. How long do you continue to fight, when death is certain? When does striving become vain hope which drains quality and creates only suffering? What makes struggle worth the …
How long do you continue to fight when death is certain?
This week my toughest case involved futile care. We admitted a patient with very advanced cancer, dying naturally at home on hospice. Because of last minute family intervention, the patient ended up spending 48 hours on super-max support, dying quite horribly with tubes and lines in every natural and unnatural orifice. Liver failure, lung failure, kidney failure, bleeding, blood clots and …
It occurs to me there are several keys to being an excellent physician. One must love science, enjoy hard work, have the courage to make tough decisions, carry a modicum of intelligence and suffer angst at receiving 94% on an organic chemistry test. In addition, the very best physicians, those we admire and to whom we flock, have a secret weapon. They do not care.
I do not mean that they …
The very best physicians do not judge their patients
If you had cancer, how good would a treatment have to be, how much would it have to help, for you to use it? How about if it gave you a 5% better chance of cure? A 10% chance? How about a 20% chance to be beat the disease using a treatment without side effects that is free? “Sign me up,” you say? Nonetheless, only 8% of breast cancer patients …
Exercise is a powerful tool in the fight against cancer
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