Palliative Care

Physicians, nurses, chaplains, and families writing on KevinMD about comfort, dignity, and quality of life in serious illness: hospice and why it is used late, the prognosis conversation, goals of care, symptom management, and what it is like to care for a dying patient. Most contributors work in palliative medicine or hospice, or have been the family at the bedside. For a maintained record of what physicians have said about dying and the decisions at the end of life since 2004, including the assisted-dying debate with both sides at equal weight, see End of life: what physicians say, in their own words.

Physician-assisted dying: Has the pendulum swung too far?

Michel Accad, MD

Physician

May 6, 2015

When a terminally ill but mentally competent patient wishes to die, should a physician be allowed to bring about such wish? The California legislature is considering that question, and physicians will soon be asked to weigh in on it. Until recently, so-called “physician-assisted dying” (PAD) garnered little support among doctors. Currently, however, enthusiasm in its favor is growing. What are the reasons given to justify this emerging practice? Do they …

End-of-life care: What I learned from a pet’s death

Abigail Schildcrout, MD

Physician

April 30, 2015

It has taken me almost two years to be able to write this. We said goodbye to our beloved dog in early May of 2013. I grieved for well over a year.

About a month-and-a-half prior to his death, we had a big medical scare with him. I wrote at that time about how dealing with a veterinary emergency can provide us with some insights and practice parallels to dealing with …

The right, or freedom, to die

James C. Salwitz, MD

Physician

April 28, 2015

The theater darkens; children stop laughing, adults sit forward in their chairs. Framed by a single light in the center of the stage, he stands; tuxedo, white shirt, black tie. He stares into the silent crowd, slowly turning his head, lips touched with the slightest, smallest, cruelest of smiles. His gaze fixes upon you; he is just feet away. His hand rises to the brim of his tall hat and …

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The right, or freedom, to die

Why code status should be modified

Natalie Wilcox

Conditions and Diseases

April 27, 2015

“Good morning baby,” she said to me each morning I when I came into her room.

Ms. K was an educated woman in her early 50s with three children. She loved drinking tea in the morning. She also had a very advanced case of lobular carcinoma of the breast that had extended into her abdomen. A cluster of cancer cells was obstructing her small intestine, causing her to have nausea, vomiting, …

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Why code status should be modified

We should strive for a good death that occurs at the proper time and place

Allen Frances, MD

Physician

April 27, 2015

Count no man happy till his end is known.
– Herodotus

This was true in ancient Greece 2,500 years ago. It is even more true today — aggressive end-of-life hospital care, the lack of sufficient palliative care, and unduly restrictive assisted suicide laws make it impossible for most people to die with dignity.

There is no worse death than a hospital death. Dying well means dying at home. This requires preparation and preparation …

An inadvertent physical exam

Bart Windrum

Patient

April 24, 2015

“Nobody does this …” Dr. D said as a greeting as he walked in holding the 700-word letter I had sent him some weeks before my periodic physical examination.

Half the letter addressed six issues that had arisen during the year and a half since my last physical. I thought, nearing age 62, that it’d be both efficient and prudent to provide my GP an update on my health experiences. Half …

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An inadvertent physical exam

Moving towards a culture of care during end-of-life conversations

Elizabeth Dzeng, MD, MPH

Physician

April 18, 2015

Americans are waking up to the fact that the $170 billion that Medicare spends on the last six months of life is not helping us die well. Instead, the way we die today tends to be protracted, undignified, and painful. Sarah Palin’s “death panel” debacle temporarily stifled all discussion on the subject, but the silence has been broken by dialogue inspired by the Institute of Medicine’s recent report, Dying in …

The metaphors of illness

Amrapali Maitra

Medical Education

April 17, 2015

In India, when the first heavy droplets of rain meet dry earth it releases a particular kind of smell: a dampness arising from sizzling soil that in Bengal we call shnoda gondho. It is raining on the second day we go to visit my grandfather in the hospital.

He has been readmitted to the hospital, after spending a week recovering at home from a hospitalization for rib fractures and bleeding into his …

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The metaphors of illness

From a hospice volunteer: Yes, you make a difference

Ellen Rand

Patient

April 2, 2015

One winter afternoon during my first year as a hospice volunteer, I drove slowly through the kind of neighborhood where the only people you see during the day are landscapers, contractors and housecleaning services and where one house is grander than the next. I was looking for the ranch house where Bobby had been living since his diagnosis.

Most people I visit, as a hospice volunteer, are my senior by 20 …

The doctor-patient relationship with dying patients

Martine Ehrenclou, MA

Patient

March 30, 2015

Perhaps we thought we could get away with ignoring the relationship between doctors and patients. The Kaiser Health News article, “Efforts to Instill Empathy Among Doctors is Paying Dividends,” explains why we can’t.

Patient satisfaction scores and reimbursements aside, this relationship was once considered the cornerstone of quality care.

Doctors are healers but in recent years many have been reduced to diagnosticians, electronic medical records (EMR) data entry clerks, and health …

The last breath can be seen as a the passage into eternity

Kathryn A. Hughes, MD

Physician

March 24, 2015

Eonia I Mnimi (Eternal Memory)
– Greek Orthodox Funeral Blessing

“Have you ever seen anyone die before?” my cousin asked me, from across the bed.

“Sure I have, plenty of times,” I answered.

We were flanking her father, my uncle (really, my mother’s cousin, but extended Greek families are complicated; suffice it to say that our families are very close). He had just taken his last breath.

***

My uncle had been declining for several years with Lewy …

Doulas for palliative care

John Schumann, MD

Physician

March 24, 2015

Ever heard of a doula?

Doula is an ancient Greek word that translates as “woman who serves.” Specifically, it’s come to mean someone who serves as a birth attendant, a person trained in childbirth who acts in support of a birthing mother. A doula provides knowledge, comfort, and an extra pair of hands — whether it’s to provide nourishment or massage, or help a mother find a comfortable position.

As you may …

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Doulas for palliative care

The vexing problem of dying for the medical profession

Dr. Saurabh Jha

Physician

March 21, 2015

Thomas Hobbes described life as pitifully “nasty, brutish, and short.” Thanks to the free market and the state, life is no longer a Hobbesian nightmare. But death has become nasty, brutish, and long.

Surgeon and writer, Atul Gawande, explores the medicalization of aging and death in Being Mortal. Gawande points to a glaring deficiency in medical education. Taught to save lives and fight death, doctors don’t bow out gracefully and say enough …

3 myths and 3 truths about hospice

Monica Williams-Murphy, MD

Physician

March 17, 2015

As I travel around speaking about preparing for peace at the end of life, I have found that there are three pervasive myths about hospice that might cause you to inadvertently rob yourself or your family of a peace-filled end-of-life experience.

So, I am taking on the job of myth-buster to clear the air. Here goes:

Myth #1: Hospice is a place. While hospice can be a place, it is primarily a service. …

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3 myths and 3 truths about hospice

A phrase as a metaphor for dying itself

Ellen Rand

Patient

March 16, 2015

In 2010, I became a hospice volunteer.

My mother had died of a brain tumor five years earlier at age eighty-seven. I saw being a hospice volunteer as a way to express my gratitude for my mother’s compassionate hospice care and to help other caregivers to weather a loved one’s passing. And, as a former reporter and writer, I thought I could help people to write their life stories, if they …

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A phrase as a metaphor for dying itself

What can we learn about palliative care from Indian physicians?

Monica Williams-Murphy, MD

Physician

February 24, 2015

Early on in my career I called an Indian internist in the middle of the night to admit a patient to him.

The patient was an 88-year-old female with advanced dementia, a terminal brain disease. She had aspiration pneumonia, which is often the final common pathway of this illness. She was in respiratory failure, in septic shock and was a “full code.”

I can still recall our 4 a.m. conversation:

“Hi, Dr. …

Let’s break the association of palliative care as hospice

Don S. Dizon, MD

Physician

February 21, 2015

Mom. Dad.

Happy. Sad.

Friend. Trust.

I remember playing this game. A friend would say one thing, and then I would say the first thing that came to my mind. For some reason, it would pass the time. I remember how some words would spark an emotion or a memory. Sometimes happy, sometimes not so happy. But, playing that game was one of …

A patient, mortally wounded by those purported to love him

Jordan Grumet, MD

Physician

February 17, 2015

Neither of the two most important people in Aaron’s life could stand to be in the same room with each other. There was a long colorful history between his ex-wife and his brother, and as his disease began to accelerate, the feuding became quite intense. They argued over Aaron’s advance directives. They both tried to coerce and manipulate themselves into commanding positions. The shouting became louder, the fury more fierce. …

The line between comfort care and murder

James C. Salwitz, MD

Physician

February 6, 2015

“So, I told the doctor at the nursing home that I loved my father more than anything. Dad was my friend and the most wonderful man I had ever known. I wanted everything for him. But, I said, Dad was sick, weak, confused, and he never wanted to live like that. The next morning he was dead. That was OK by me.”

I once participated in a panel discussion about hospice, …

I’m a palliative care doctor. This is what I do.

Andrew Thurston, MD

Physician

February 1, 2015

Some people who know what I do don’t really know what I do.

They picture me floating through the hospital extinguishing lives, blowing them out one by one like candles down an endless corridor. They think I practice euthanasia, that my presence alone hastens death — that I consume hope and happiness like a black hole, compressing it all into nothingness. Some call me the Grim Reaper, others the Death Doctor. …

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