If you're like most Westerners (which, I assume you are since you are reading my blog), you likely haven't thought too much about your death. In fact, if you're like most Americans, you probably have never seen someone die nor do you likely have the most pleasant feelings regarding the death and dying process. In fact, you probably want to avoid death at all costs and are pretty much willing to do anything to do so. Right?
The feelings of avoiding death (ie, survival) is biologically engrained in all of us. It is normal to want to live. It is normal to want to fight to live. But, it is my opinion that in Western society, we may be taking the avoidance of death and aging a bit too far. Annually, Westerners spend billions of dollars on beauty and lifestyle products to make us look feel and healthier. But are we really any healthier than those of other societies with much less? Yes, we have increased the average life expectancy (now in the late 70s, early 80s for women I believe), but how's our quality of life? Westerners are definitely living longer, but as a result, we suffer from more and more chronic diseases (diabetes, heart disease, dementia, cancer, etc) which debilitate us more and more (examples - diabetics may lose limbs or go blind; cancer survivors are almost always left with long-term side effects of their treatments, whatever they may be), causing us to be less and less happy and on more and more medication (ie, anti-depressants). Many elderly, frail patients end up in nursing homes without family or friends around. Is this really what early 20th century docs and public health officials had in mind? Is replacing a heart valve with one from a pig or made from metal really the way to go when an already fragile person does not have more than 3-5 years of life left? What are the risks of the surgery? What will the person's life be like after surgery? Will they be able to walk, talk, dress themselves, enjoy the company of friends and family? These are the unknowns of medicine and I definitely don't have any concrete answers as much of them are based on the individual and what they value in life. If a 45 year old man is diagnosed with a moderately curable cancer (G-d forbid) and seeks treatment in order to save his life, so be it. This is MUCH different than a 78 year old frail woman needing heart or abdominal surgery. These issues are very complicated, sending some in to a tivvy (myself included).
The reason I bring this up is not so much to discuss the ethics of medical treatment. It's more to discuss the ethics of non-treatment and to convince some of you that palliative care (ie, hospice care) is a humane and practical form of medical care that is not embraced as often as it should be. I attended a very interesting conference at the hospital today on the conflicts health care practitioners face when caring for the dying (I won't go in to details about the actual conference as I swore to keep it inside the room (HIPPA)). To start, I want you to keep in mind that nurses, doctors and other healthcare practitioners experience just as many conflicting emotions about their patients' deaths (and lives) as the patient and their families. We are, after all, human. And no amount of training can take that away.
Anyways, the conference discussion brought up some very salient points about our current mentality on death and dying. One of the main points was that there is a disconnect between the services provided by palliative care teams and what the public perceives these services to be. To be "on palliative care", you a) must meet specific criteria (ie, have a terminal illness or condition for which your life expectancy is predicted to be up to 6 months) and b) can still receive antibiotics, fluids, wound care, nutrition, etc, etc. You are not left to wither away and die alone.
In fact, a study from last year's New England Journal of Medicine found that early palliative care team involvement enabled patients with newly diagnosed metastatic non-small cell lung cancer to live 3 months LONGER than those on chemotherapy without palliation. These patients, like their control group counterparts, received chemotherapy as well as "comfort care" from nurses specially trained to take care of their day-to-day needs - pain, nausea, malnutrition. Not only did the patients in the palliative care group live longer, but they also reported significantly higher scores on questionnaires focused on their quality of life (defined as physical, functional, emotional, and social well-being) and mood (anxiety and depressive symptoms)! Although the study was not perfect (they hardly ever are), I find it to be quite refreshing as well as confirming of what I already know - palliation is not a bad thing. However, until we as a society can come to grips with our fear of death and dying, I believe it will be a far too often underutilized modality.
Something to think about and discuss with your families and health care practitioners. I'd love to hear your feedback.
Have a great rest of the week!
Reference source: Temel JS, et al. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. N Engl J Med 2010; 363:733-742.
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