Tuesday, April 14, 2020

A physician finally says it - will they listen?

Where ya goin', bud?

I’ve come to the conclusion that lots of people in palliative medicine are afraid to talk about death. It’s ironic but also no surprise. We’re all afraid of dying.

I think Ernest Becker had the right idea: “...death-denial often shapes our behavior in highly subtle and unconscious ways.... Medicine has death-denial built in to its core; it is designed to prevent or delay death.”

In terms of clinical practice, I don’t think it’s a good idea. I think it fails the patients and families who have/will experience death in this pandemic.

I’m glad that Amit Arya and Naheed Dosani finally broke the ice among physicians:

“... the use of a ventilator is a very aggressive form of treatment that requires the patient to be deeply sedated. And outcomes are often poor. Many patients who are put on a ventilator do not survive. Some who survive will never return to their previous health. With proper counselling and the promise of good palliative medical care to ease suffering and symptoms, patients such as the frail elderly or those with serious complicating disease, who have poorer prospects on ventilators, might well choose not to face the rigours of the ICU. In other words, they might choose to die in peace.”

One more time for folks in the back:

“In other words, they might choose to die in peace.”

Thank you!

A peaceful death is one of three viable goals for care. We can only pursue one goal at a time.

  1. Try to beat an illness, go for the cure, aggressive treatment;
  2. Try to manage an illness, set limits on measures or time frame, selective treatment;
  3. Try to achieve a peaceful death with treatment focused solely on comfort.

Clinicians tend to make things more complicated and confusing for patients and families, especially in crises and/or academic medical centers. This usually includes way too much talking, running down rabbit holes, and frustration.

So instead of “goals for care” conversations, talk about “the goal,” and assess all actions in the context of whether they support or undermine it. The National POLST form is built on this paradigm.

Thanks for reading - see you next time.

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