Tuesday, December 16, 2014

Palliative Care is a Win Win for Everyone

It's hard to believe that I was never really taught about how to control pain when I was in medical training.  Well that's not quite true.  I was told to avoid getting patients "hooked" on narcotics and this was certainly drilled into nurse training also.  We learned about disease and disease processes, but not about a holistic view of the patient in their social milieu.

Partly because of this, and our funding mechanisms, medicare and insurance companies organized to pay for disease care - especially procedures.  Procedures are easy to count and easier to control than "soft" care such as a doctor spending 30 minutes trying to sort out a confusing medical condition.  The "procedure based" specialists like radiologists, orthopedists, ophthamologists, gastroenterologists, and cardiologists do disproportionately well historically playing by established reimbursement rules, even though the procedures may be over-utilized.  Costs soar.

Finally we're beginning to look at global costs related to uncoordinated care, poverty, cultural barriers, etc.  The Institute of Medicine (IOM) has a key report on "Dying in America".  This report from the Center to Advance Palliative Care highlights the current changes in health care delivery under Medicare and Obamacare.  It's a must read.  The needed changes appear to be gaining traction.

Wednesday, December 3, 2014

What's a Good Death?

When someone asked a philosopher how he would like to die he replied, "When I least expect it."  Woody Allen in a similar vein stated, "I'm not afraid of dying, I just don't want to be there when it happens."

Although we all may have similar wishes, we are vastly more likely to age slowly, acquire a few chronic conditions, have periodic illnesses with declining health, and then have some kind of "terminal event."  So most of us have time to think about a "good death", but what does that really mean?

There was a recent piece in the New York Times written by a knowledgeable woman, whose father didn't die the way he wanted to - no heroic interventions at the end.  He had a sudden cardiac arrest with subsequent cardiac resuscitation and invasive ICU care.  Once the CPR was initiated it was unclear at to whether her father would survive.  To me it demonstrates that all situations can't be anticipated and that often families need to sit down with the medical team participating in shared decision making.

So what is a good death?  I was asked this question by our local NPR radio station.  After talking to many patients over the years, the following seems most important to have our own wishes adhered to:
  • Pain and symptom management - palliative care consultation and hospice are often needed
  • Preparation for death – spiritual & natural - advance directives - POLST if indicated.
  • Completion of goals - each individual has his/her own wishes
  • Contributing to others – a legacy
  • At peace surrounded by loved ones - most people wish for a home or home-like death.  The ICU isn't a peaceful place necessarily, but at times I've felt a spiritual connection when tubes are removed, monitors turned off, and the family holding and talking quietly to their loved one at the end.

The funeral as we know it is becoming a relic — just in time for a death boom

By   Karen Heller April 15 Ed note: Funerals are changing in ways that will bring culture shock and a shake of the head of s...