Many years ago when I was a “young” doctor, moonlighting in the ER of a tiny country town, I had an experience that challenged my training. You see, most young, new doctors often think their training and knowledge is superior to that of “old” doctors, which is often malarkey. A wise and sage old doctor in this tiny country town taught me an important lesson on where and how one …
What an old doctor taught me about palliative care
“Did you sell the business yet?”
I marvel at my patient Jack: despite his breathlessness, he’s somehow managed to greet his wife Sara with a complete sentence. Given his condition, it’s truly amazing.
Most of his lung function has been devastated by his forty-year, pack-a-day smoking habit; the rest has been demolished by cancer. The easy, automatic breathing he once took for granted is just a memory. He can’t even lie down …
Some people choose the time of their death
In his beautifully written, recently published novel “And the Mountains Echoed,” Khaled Hosseini presents a series of stories in which individuals are faced with near-impossible choices.
Impossible choices permeate Khaled Hosseni’s latest novel. Studies show many doctors struggle to help their patients through their most difficult choices.
As difficult as the decisions in the book seem, it turns out the …
The majority of patients are stronger than many doctors realize
Advanced dementia is a terminal illness needing palliative care. Unfortunately, there is a great divide between this statement of the world as it should be, and the current reality of the world as it is. Rates of pain and shortness of breath are high for patients with advance dementia. Patients with advanced dementia often reside in nursing homes, and few nursing homes offer specialized palliative care services.
And, as we can see from an …
Communication about prognosis and goals of care is still lacking
Earlier this month, a candid and powerful personal essay was published by Jessica Rice, a thirtysomething woman with terminal cancer. An emerging theme of Jessica’s piece was the importance of frank conversation between physician and patient, and I was curious what a provider — someone who has difficult conversations on an almost daily basis — would think of this patient’s story and perspective.
Thoracic oncologist Kavitha Jennifer Ramchandran, MD, read the piece …
Communicating with patients with serious or terminal cancers
I remember when Susan*, a close friend of mine with breast cancer (who had been living with metastatic disease for about a year before), was told she was terminal. Beyond the shock and fear, Susan felt grief and anguish that her life would end so much sooner than she (or any of us) had expected. Suddenly, Susan had so many big …
There can be hope at the end of life
There was nothing wrong with Sarah’s vocal cords. Her tumor had spread throughout the abdomen, but her voice was unaffected. Yet minutes after learning of the voraciousness of her metastases, she pursed her lips and began to communicate with head nods and hand gestures only.
I met her for the first time in the nursing home. I sat down quietly at her bedside on a Sunday morning. I was in the …
This is what’s so difficult about doctoring
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
After getting off a 15 hour call day, all I want to do is write.
These past 2 weeks death has been on my mind a lot, more than it ever has been. I have always known that physicians counsel patients and families on dying, but actually being the one to do it is entirely different.
How do you tell someone that their best medical option, the best thing you can offer …
The price for improvement sometimes outweighs the benefits
After finishing medical school and my residency in internal medicine, I undertook an additional year of training in a field called palliative care. Patients who notice my background sometimes ask me what exactly palliative care means. It’s really a simple concept. Palliative care is helping people with a serious illness have the best possible quality of life. It’s enabling sick patients to make the most of the time they have left …
Defining the 3 goals of palliative care
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
In 2008, the state legislature of Washington passed what was called the Death with Dignity Act, a law that legalized physician assisted suicide. Under the law, terminally ill patients (predicted to have less than six months to live) can request prescriptions for lethal medications from their physicians, under a series of safeguards: multiple requests for example, determination of competency, and the like. Then, if the patients so choose, they can ingest …
Don’t confuse death with dignity with suicide
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Good old Earl Blumenauer. A bespectacled and bowtied Congressman from Oregon. He of the “death panel” proposal. Thank God he’s still here. Presuming that the crazy talk over the provision in the Affordable Care Act that would have paid doctors to discuss end-of-life issues with patients is over, he has introduced a separate bill with this provision and hopes to get it passed in the next couple of …
Billing for end of life conversations needs to be an honest discussion
When socializing with fellow young physicians, most of whom are not in palliative medicine, I am reminded that I have the unique opportunity to share time and attention with my patients. We reflect on “the old days” of medicine, where physicians had long standing relationships with their patients which allowed them to more easily direct medical decision making which was appropriate for the individual patient. I often tell others I …
Standing up from my computer terminal to go see another patient, I caught a glimpse of a small, spindly frail woman being rolled by paramedics into one of my shock and trauma rooms.
Very calmly, I remarked, “That woman is dying.”
The medical student who was rotating with me was unnerved that I would make such a pronouncement out of a mere casual observance, “Oh my goodness! How can you just say …
Failing a patient 3 times: A case of moral medical malpractice
Recently, my family experienced the loss of someone very dear- Uncle Peter. Peter was an ex-Marine, father of three men, and patriarch of my spouse’s family; not to mention, husband to my wonderful and artistic Aunt Helene. He had been admitted to an outside hospital with leg ischemia and was transferred to a tertiary facility. Unfortunately, things did not turn out …
Lessons learned from a family meeting
“Got a new admission for you. 93-year-old male with end stage kidney disease on dialysis, coronary artery disease, hypertension, diabetes, peripheral vascular disease here after being found unresponsive. Oh by the way, I think he’s DNR/DNI.”
It’s like music to the ears of any medicine resident. I’m still not entirely sure why this phrase brings such relief, but I’m in my last year of residency and still exhale a little bit …
Reflecting on DNR/DNI after being a code team leader
I knew from last night’s house call that my patient Bessie’s time was near. All day long I’d felt the familiar churning inside, the sickly sweet combination of anticipated dread and anticipated relief. So when the phone rang while I was exercising at home, I wasn’t surprised. I quickly dropped the barbell weights to answer the call before it went to voice mail.
It was Bessie’s daughter, Susan.
“Mom is gone,” she …
The words I say aren’t as important as my presence
Hospice faces numerous societal obstacles in providing care for transgender patients. I recently witnessed a striking example of this in our local community hospice. An elderly individual assigned female at birth (MTF) was suffering from metastatic cancer. Chemotherapy had proven ineffective and had left her profoundly weak and infirm. With no connection to her family, she had only a few friends to rely on, but even they were only available …
Hospice care for the transgendered patient
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