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.
Vermont became the first state to enact a law authorizing physician-assisted suicide through the legislative process. As the governor signed the bill, Jean Mallary watched carefully over his shoulder. She’s the widow of the late Dick Mallary, a former speaker of the House and U.S. Congressman. Mallary was in pain and suffered from terminal cancer when he chose to end his life over a year ago. Jean Mallary’s story …
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Death with dignity: Issues states need to consider
One of the benefits of being an oncologist is that, as a rule, people appreciate our work. That does not mean they want to hear about our day, and the response when someone learns my vocation is rarely, “Hey, that’s sounds like fun!”
Nonetheless, at least there is a modicum of respect. However, I found a group of people with major questions about the work of cancer docs or at least …
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The tension between oncology and palliative care
By typical end-of-life definitions, Nelson Mandela is dying (he is in critical condition after a lengthy hospital stay, and has had multiple recent admissions). Those of us in the healthcare professions see this end-of-life equation all of the time: increasing severity of illness and frequency of hospitalizations plus advanced age almost always equals dying. Now, everyone likes to believe this equation may be altered by hopes, prayers, and modern medicine. …
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Nelson Mandela: Recognize the end of life equation
If I had to choose the way I could die, I would probably like to go peacefully in my sleep. It seems that Nelson Mandela no longer has that option. He may have had, and perhaps even been on that trajectory when he was rushed to hospital in the middle of the night more than two weeks ago. It would not have …
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Nelson Mandela: His doctors and nurses also need our thoughts
As part of the first-year curriculum, medical students at the David Geffen School of Medicine at UCLA are required to attend chaplain rounds at local hospitals during which they accompany chaplains to offer spiritual care to patients. This is designed to encourage students to empathize with patients who are enduring difficult end-of-life issues and is part of a ubiquitous and important theme that inundates almost every medical student across the …
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The reality of medicine’s inherently unequal power dynamic
Blanched by anemia, Mary rested quietly in the hospital bed. Her pallor made her barely visible amid the bleached bed linens–she seemed a mere shock of white hair against the pillowcase.
Age ninety-three, she’d visited the hospital a half-dozen times in as many months, shuttling between nursing home and hospital as many elders unwittingly do in their last year of life. She may have preferred to stay put, but no one …
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Dying a hero’s death
I couldn’t really blame the social worker. He was just doing his job. The skilled nursing facility (SNF) connected to the hospital was full of flailing patients. So he thought he would ask for a palliative care consult (after getting an okay from the primary team). It was his third request of the day. He spoke slowly as he tried to untangle the twisted path the patient had taken.
“Dr. X …
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Palliative care has become the last bastion of health care sanity
An 85-year-old woman with moderate Alzheimer’s disease who enjoys walking in her nursing home’s garden with her walker has fallen and broken her hip. An advance directive signed by the patient states a preference for “comfort measures only,” and specifically states that she does not want to be transferred to the hospital. The physician believes that surgery would provide long-term pain relief and the chance to maintain some mobility.
What do …
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When can you override an advance directive?
Perhaps it’s because I love the practice of medicine so much. Or maybe it’s because doctors (and teachers) have always been my heroes.
I’m trying to sort out why I feel so offended by Paul McHugh’s editorial in the Wall Street Journal. His sensational and paternalistic view of physician-assisted suicide can be summed up in one word—shameful.
It is true, thankfully so, that in the United States offensive speech is protected. And …
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Americans too often lose autonomy at the end of their life
What is a natural death, anyway?
I get it – death is part of the cycle of life. Seasons change. The moon waxes and wanes. We are born. We die. Death is natural.
But what is a “natural” death? Seriously, what comes to mind when you think of natural death? Here is a video of a natural death, taken from the Planet Earth series:
Death in nature is often violent, brutal, …
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A natural death: What exactly does that mean?
Advancing technology has allowed life to be simple. Nowadays, when you go shopping, you slide a credit card and voila, sold. Why does it seem though some things are getting more complicated?
Dioctyl sodium sulfosuccinate is another name for Colace. We are forced to have two names for one drug: a brand name, and a generic. The pharmaceutical companies tell us they have patents mandating we live in their complicated world, …
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End of life care is too complicated
To resuscitate or not to resuscitate, that is the question. Whether ’tis nobler to beat the heck out of a person on his or her way out in the hope of saving his or her one precious life, or to allow death to proceed at its own pace with expectation of a peaceful passing.
The United States has come a long way in the last 2 decades since 1991 when the …
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Improving informed consent for resuscitation without playing God
The Atlantic this week published a provocative article entitled “The Robot Will See You Now.” Using the supercomputer Watson as a starting point, the author explored the mind-bending possibilities of e-care. In this near future, so many aspects of medicine will be captured by automated technology that the magazine asked if “your doctor is becoming obsolete?”
The IT version of health includes continuous medical monitoring (i.e. your watch will …
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Will patients trade human imperfection for computerized perfection?
“J.T.” is 92 and clearly a soul who lives to the beat of a different drummer. She has no children and her closest relative is a niece who she despises. Despite this the niece oversees her care, sending in a full time aide and her personnel assistant to run the household. J.T. will not come to the office for a visit. If I call and make an appointment to see …
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Why we cannot keep the costs of end of life care in a reasonable range
The unexamined life is not worth living.
–Plato
There are obstacles to dignity at the end of life. Disease inflicted pain and debilitation, cost and confusion, poor planning and fear, all aggravated by our societal ignorance regarding dying, result in unneeded suffering and isolation. In addition, it occurs to me that a hindrance to control and quality is that we are overwhelmed by the pressure of our day-to-day lives. In other words, …
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We are simply too busy to die
I write a lot about end of life conversations that go well or have unexpectedly positive outcomes. But to be fair and balanced, you should also hear about the ones that don’t go so well, lest you be led to believe that I have magical powers over my patients and their families.
Here are two of my attempted end of life map conversations that did not go over so well. In fact, …
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4 tips to remember when end of life discussions go wrong
Watching my grandfather pass away changed my life. It wasn’t sudden and it shouldn’t have been unexpected. Yet it seemed unnatural, mysterious, and incredibly uncomfortable. I can still remember receiving the phone call from the hospital, my mother letting out a distraught cry that my grandfather was no more. My initial reaction was shock and confusion: I just couldn’t understand what had happened. Looking back, he had been under intensive …
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Watching my grandfather pass away changed my life
It had all been so easy when Jim was still around. Lisa’s ex-husband had many shortcomings, but being a critical care specialist sure came in handy. Any time her mom or dad had a health crisis, he was right there in the middle of it: advocating, interpreting, breaking down the complexities into easily digestible morsels of information. But then Lisa’s father died, and the emotional and physical stress brought the unstable union …
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If only the patient had an advocate
We are frequently reminded by the General Accounting Office and CMS that a great proportion of Medicare health costs are incurred in the last three months of a patient’s life. Health care policy experts have tried to reduce these costs by encouraging end of life planning. Living wills, health care directives and the availability of hospice and palliative services will not put a dent in these costs because of human …
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Human nature prevents any cost savings at the end of the life
When I attended the Association of Health Care Journalists (AHCJ) conference in Boston recently, discussion swirled on the topics of unsustainable costs of care, doctors’ incentives under traditional payment models to order more tests and treatments, and the struggles of patients’ family members to avoid unwanted care at the end of life. That Sunday night, I was back at my day job (so to speak) in …
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End of life discussions require all hands on deck
