I have no intention of devoting this blog to nothing but palliative care, but since one of my patients brought it to my attention, I can't help making sure anyone who reads here has seen a few of the articles that relate to end of life discussions. An excellent article in the NYT discusses the recent law passed by their legislature which requires practitioners to "offer to provide the patient with information and counseling regarding palliative care and end-of-life options appropriate to the patient; the prognosis, risks and benefits ..." Although many (including the NY state medical society) object to this as an intrusion into the doctor-patient relationship, my personal view is that we often continue ineffective treatment far too long. Taking the time to counsel patients is not well-compensated, but in the long run, it is both ethical and may be in their best interest. Randomized controlled studies often show that quality of life improves with palliative care-focused interventions compared to usual oncology care. Indeed, a recent article in the NEJM demonstrated that early palliative care intervention in non-small cell lung cancer resulted in IMPROVED survival since patients did NOT receive aggressive end-of-life care.
" Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P=0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02)."
The ASCO QOPI program includes both guidelines and processes to help us better employ palliative care and hopefully will be increasingly adopted by most of us with or without legislative initiatives.
Anees B. Chagpar, MD, MPH, MBA, MSc, MA, FACS, FRCS, FASCO
Aug, 29 2010 10:09 PM
It would seem to me that discussing options in patients' care is part of the doctor-patient relationship -- not an intrusion into it. Many states have passed laws that mandate that physicians discuss options -- the options for partial vs. total mastectomy, options for reconstruction, etc.. This is all in the spirit of ensuring that we keep patients informed . . . and who wouldn't want a better informed patient? The backlash against talking about palliative care comes from the concept that it makes people uncomfortable to shift from "treatment" to "palliation". . . we like making people live longer, not die sooner. But the NEJM article demonstrates that alleviating pain not only improves quality of life and reduces depression, but increases life expectancy! So much for the "death panel" theory . . . PS: Here's another NYT article you may find interesting: http://www.nytimes.com/2010/08/19/health/19care.html