This blog is a little far afield from my usual rants, but it discusses a subject on which I have strong personal feelings.
I received a telephone call from my mother last night to inform me that my uncle (my father's brother) had died. He had suffered from many ailments and his decline was agonizing both to him and his family. It caused me to consider my father's death at about the same age in 2013, and consider that one of the differences was the amount of hospice care each got.
This announcement came atop an e-
zine article from Medscape Oncology about death and dying I had received via email in which Richard Smith, a former editor of the British Medical Journal made some
challenging statements about the utility of cancer chemotherapy,
his peers reacted strongly, and there was
discussion of the
IOM report on Dying In America.
All are worthy of a read. The question that is raised in all this is when do we stop trying to cure and focus instead on providing closure and comfort for an inevitable death?
The discussion is one most of us find uncomfortable, at best.
Smith's comments are, I suspect, intentionally provocative, but they do raise some interesting questions about a uniquely American tendency to try to flagellate the last microsecond of life out of our mortal coil. Certainly the point he makes about the ability to exit life in relative comfort and be given the time to get closure with those nearest and dearest to them is worthy of consideration.
My twin brother (a physician) is a Palliative Care specialist who confronts this question head-on every day. My discussions with him have prompted me to ensure that there is an advanced directive that will override anyone's decision to try to keep my flesh alive at the expense of quality of life for both me and my family. I cite this as reflective of a personal decision, not as direction to anyone else. However, the IOM report cited above pretty clearly point out the benefit of such action.
As medication specialists, how do we become involved in this decision? Or do we?
There are several studies that indicate palliative care either associated with oncology treatment or in place of it produces both better quality of life
and better longevity.
Temel et al investigated the application of early palliative care to non-small-cell lung cancer patients that was maintained to end-of-life produced both better quality of life and longer survival by approximately 2 months (NEJM 8/19/2010).
Connor et al investigated the impact of hospice care on the survival of terminally ill patients with CHF, breast cancer, colon cancer, lung cancer, pancreatic cancer and prostate cancer, and discovered that mean survival for all diseases was 8 days longer for hospice patients (P = 0.00079). However, for three of these diseases (CHF, lung cancer and pancreatic cancer), survival of the hospice group was 29 days longer than those that received standard therapy. CHF patients who chose hospice care lived an average of 81 days longer than those that did not. (Connor
et al., Journal of Pain and Symptom Management, 33(3) 3 Mar 2007, 238 - 246)
Pyenson et all investigated the impact of hospice care on Medicare cost of care for matched hospice and non-hospice cohorts and determined that mean cost Medicare cost of care was lower for patients with CHF, liver cancer and pancreatic cancer (Pyenson et al, Journal of Pain and Symptom Management, 28(2) 3 Sep 2004 200-210)
In
2007 study of patients in the last 72 days of life conducted by Taylor et al at Duke University, hospice patients averaged $2309 less expense than non-hospice patients (Taylor et al, Social Science & Medicine 65 (2007) 1466-1478).
I leave it to the reader to evaluate these studies for themselves. If what they report is true, do we have an obligation to question decisions to pursue aggressive treatments with a poor prognosis? Is attacking the disease with everything in our armamentarium always preferable?
I am not going to burden you with my opinions other than to say that the answer to these questions certainly lies in great measure in the hands of the patient and their family, as it should.
I will, however, urge you to think about this matter both in terms of your personal decisions, and in terms of the patients whose care you may manage.
What do you think?
Dennis A. Tribble, Pharm. D., FASHP
Daytona Beach, FL
datdoc@aol.com
The opinions expressed in this blog are my own, and to not reflect the opinions of my employer or of ASHP