Wednesday, March 24, 2010

Palliative Care: An Overused Subspecialty?

The #1 Dinosaur has a provocative post from last week about palliative care medicine. Her point is that, too often, primary doctors neglect their duties as physicians and pawn off the undesirable aspects of comprehensive care (end of life issues, vague abdominal pains, constipation, depression/sadness) onto specialists.
Excuse me: why do you need a brand-new "Team" to treat symptoms and talk to families?

True palliative care -- the management of symptoms -- is part and parcel of everyday medicine. Itching; nausea; constipation; pain. Work them up to make sure there is no serious underlying problem, of course, but for crying out loud, don't tell me you now need another specialist to actually come TREAT them! This is fragmentation of care taken to outrageous extremes.

Her argument is compelling. And the dialogue that ensues in the comments to the post (from Palliative Care docs like Christian Sinclair and Eric Widera) is equally persuasive. I fall somewhere in the middle. I agree with Dinosaur to a certain extent that primary care docs need to be more aggressive in addressing end of life issues, even when the patient is ostensibly healthy. You don't want to wait to discuss hospice plans until you're intubated in some random ICU with numerous liver metastases wracking your body. The problem isn't entirely the fault of internists and family practice docs lacking the courage to compassionately address terminal issues, however. Most doctors simply aren't certain of how to navigate this senstive terrain. Medical students aren't exposed nearly enough to the philosophy and psychology of death and dying. (Do we really need to spend four weeks during the second year memorizing the differences between Freudian, Jungian and Piagetian psychobabble?) Furthermore, all residencies, no matter what the specialty, need to incorporate either a rotation on a palliative care floor or multiple intensive didactic sessions dedicated to end of life issues and pain palliation options. (General surgery residents would especially benefit.)

On the other hand, sometimes it's nice to have a palliative care "team" available for those truly futile cases to give the patient and their family additional perspective. I have a tendency to stay optimistic about a case for too long sometimes--- I'm always strategizing ways to "make the patient better", longer than what the objective clinical data warrants. When futility is too obvious to ignore it's sometimes very difficult to make that transition, as a surgeon, from aggressive advocate of healing to the voice of realistic resignation. It's hard for me and it's hard for the families involved. It can seem as if I've too suddenly changed my mind, which can trigger doubt (in my judgment, my clinical expertise, etc) in the minds of the patient and his loved ones. So I have found it is constructive to say to a patient's family, "you know, things don't look so great right now. It's becoming apparent your mom is not pulling through the emergency surgery the way we had hoped. I think it would be helpful for you all to speak with the people from our palliative care team, to hear a different perspective, and maybe then we can reconsider our options." It just helps smooth the transition from the full-court press of intensive treatment to the more realistic phase of saying goodbye.

4 comments:

Frank Drackman said...

Howcome everybody thinks everybody elses specialty is so easy/overpaid/useless??? There's no such thing as a worthless/overpaid/useless doctor, except maybe for Neurologists...
Really, 70 years and there no closer to curing Lou Gehrig's Disease than when Lou Gehrig was still playing for the Yankees...
Psychiatrists arent really needed either, I can get my OWN prolixen thank you very much...
And how hard is Surgery?? I used to operate on Pigs and most of em lived, and I'm clumsy as hell...
Anesthesia??? same gases we've had for the last 20 years, same local anesthetics we've had for the last 10 years.
The plain truth is dying people are creepy, the only thing creepier is people who choose to work with dying people, heck, they make Pathologists seem halfway normal...

Frank

Anonymous said...

I’ve noticed that for some, there is a tendency to walk away from a “mess” out of pure selfishness. Lost is the ESSENTIAL responsibility to follow through with careful patient/family prep (yeah, before going in again…) as well as especially caring DNRCC orders postop or there WILL BE SUFFERING.

For these guys, someone clearly has to intervene and better it be palliative care, because I’ve found I am viciously territorial and unforgiving.

-SCRN

ParatrooperJJ said...

It is hardly overused. Given the lack of pain control routinely seen in end of life patients under the care of their standard doctors, we need a great deal more pallative care specialists, not less.

The Happy Hospitalist said...

I love my palliative care service at my hospital. It's an NP driven, physician headed service that bills independently and they have all the time in the world to talk with families about the important end of life issues and realities that I nor most doctors have the time to really do a great job at. It's a service every family should ASK for.