Physician Voice

Opening Debate on End-of-Life Medical Care

By Dr. Carlos Picone

One of the most difficult areas confronting patients and doctors alike is the one pertaining to “end of life.” We are all aware that the only certainty after birth and hence life is… death. The difficulty is addressing the health issues that inexorably arise towards the final stages of life and providing an adequate solution while balancing burden of treatment with the one imposed by the clinical ailments.

Since the times of Hippocrates, and likely since the dawn of humanity, people have struggled with these decisions that permeate every aspect of life: Risk / Benefit assessment, or more treatment, accepting some burdens, and possibly regaining health; or comfort measures, avoiding discomfort but “giving up” on potential curative interventions.

The development of Intensive Care Units and medical technology has led to the false perception that this increasing medical technology somehow makes death optional.

Unfortunately, and as most practicing critical care doctors will promptly admit, some of what we do in Intensive Care Units today is prolonging the dying process with profound physical, emotional and financial burdens to patients, families and society with minimal gains except sometimes a sense of “duty accomplished."

Let us review this special feeling:

1. The patient may feel obligated by his inner hopes and willingness to satisfy his family, to get more treatment and not “give up,” however poor the chances of a meaningful response.
2. The family may feel obligated to support the patient’s “fighting spirit” and desire to endure all suffering to recover.
3. The physician and health-care team are trained to re-establish health and it is only natural that they are willing to fulfill the patient’s and family’s request for more aggressive care. And it is also easier to address problems as they arise without much questioning or analysis.

Technological and medical progress has increased life expectancy. Most people in our society will not perish due to an acute unexpected and devastating problem but due to the summation of small problems and progressive debility with consequent decline of the repair mechanisms and declining physiologic reserve. When our patients become sick and debilitated, health problems bring about new problems and we, as physicians try to plug up the holes as they develop.

Sometimes it is more difficult to step back and look at the ship crisscrossing the canvas of life than to concentrate on that hole in front of us. Despite its difficulty, physicians and all people should try to look towards the horizon or simply in the mirror and reviewing the entirety of the person in front of us, ask the question, “Quo Vadis?” (“Where to?”).

The answer is not always clear, but nature and disease have their way of imparting their codified message. If despite interventions there is progressive decline, if the likelihood of quality survival as defined by patient and family is poor, then it is time to review the goals of care and limit aggressive, frequently expensive interventions which prolong the dying process and not “life”.

As a profession, we frequently fail to define the goals of care early on and to continuously update this process. Patients seek solutions and have hopes of re-establishing health, and we are willing to step in and provide more treatment, however dismal the prognosis and how poor the chances of recovery.

Let me share with you a recent “tour of duty” one of these past weekends. Ten patients were admitted to the ICU, frequently consulted by my able and well-meaning colleagues. Unfortunately, if we, as a profession were painfully honest with these patients and their families, four of them would have been sent home with hospice care or would have been admitted to low acuity areas of the hospital for comfort measures, as the last pages of the final chapter of their lives were evolving. Many of the other patients will survive this hospitalization only to return to our ICU or other ICU’s in town within weeks and months adding to our healthcare expenditure and to their collective suffering with minimal gains. Only two of those patients, if they survive this acute and severe illness, will be able to return to a full and productive life.

Last year, researchers analyzed a group of more than 300 patients with advanced cancer. Surprisingly, only a third of them reported ever having discussed end-of-life issues. This group had lower rates of depression, had less aggressive and costly medical care and better patient perceived quality of life. (1)

Why do physicians shirk from their duty to address this important and all defining aspect of health care? Is it because addressing the “Goals of Care” and confronting our limitations is painful and uncomfortable? For some physicians, to “plug up the hole” and move on is easier and the “right thing to do”. For others, it is what the patient and family are demanding and what they will deliver. Yet for a minority, more care translates into more financial gains and therefore more aggressive measures, medications or additional treatment are provided with the consequent rising physical, emotional and financial cost to the patient and all parties involved including society.

We realize that we should use utilitarian justice, providing treatment and support to the greatest number of patients likely to benefit and survive. Utilitarian justice requires that we maximize our limited resources spreading benefits across all individuals. Yet, we continue to provide all care and all resources without attention to this important premise. We maintain individuals with advanced non-verbal dementia on hemodialysis, knowing that dementia is a progressive and fatal disease. We provide one more chemotherapy cycle when the patient’s decline indicates the chance of survival is negligible. We put humans on breathing machines when their respiratory failure is so advanced that chances of recovery are next to nil.

In closing, let me offer some simple advice:

1. Life is limited. We will all reach a point when additional interventions and more care are futile. Physicians frequently can help determine when that point may be near and sometimes, a new physician summoned to care for progressive problems may be more objective than the familiar face.
2. More intervention is not always better care or good medical care. It could be just more expensive care, frequently fraught with unintended consequences, more anxiety and more pain. Somehow, we should decrease or eliminate the financial incentives for physicians and the health-care system to do more, however poor the results of those interventions may be.

3. Physicians need to understand what “Doing Everything” means to the patient. This phrase usually does not imply that the patient wants every burdensome life-prolonging treatment with a small chance of benefit. After exploring what the patient may want, the physician should propose a “philosophy of treatment.” plan of care consistent with the patient’s values(2).

4. We should all support the introduction of an industry independent Comparative-Effectiveness Centre funded through health-care reform to help us invest our limited resources in most effective care. It does not imply that other means of care will be off limits. It may just mandate that our health care system and society at large are not stuck footing the bill for ineffective or lesser forms of therapy.

5. Prevention is important and we should all remain physically active, exercise, walk, take the stairs, bicycle, embrace immunizations and pursue sensible preventive medicine strategies like the ones published by the U.S. Preventive Medicine Task Force.

6. The cost of healthcare will continue to rise, unless we are all willing to make small sacrifices. Patients and physicians could wait one more day for a test; take generic drugs when possible; become more involved in health-care decisions; question interventions and procedures that may have a small chance of success and fully consider risks and benefits.

The sunset of life and the “last breath” will arrive, usually sooner than we would like. Patients should discuss with their families what they would want in the event of catastrophic illness and physicians should make an effort to promote these discussions. Those who choose not to, do so at their own peril while frequently causing themselves and their families unnecessary suffering and adding needless expense to all.

Addressing these issues is part of physicians’ Hippocratic duty. That follower of Asklepios at the island of Kos, 2500 years ago admonished:

“Refuse to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless.”
- Hippocrates –

References:
1. Wright A et al. Associations between end-of-life discussions, patient mental health, medical care near death and caregiver bereavement adjustment. JAMA 2008; 300(14):1665-1673.
2. Quill, T et Al. Discussing Treatment Preferences with Patients Who Want “Everything”. Ann Intern Med. 2009;151:345-349

Carlos E. Picone, MD; FCCP; FACP
Carlos E. Picone is on the medical staff of Suburban Hospital in Bethesda, Md.; specialized in Internal Medicine, Pulmonary, Critical Care and Palliative Medicine, a private practitioner in Chevy Chase, Md. and a physician volunteer with MobileMed Clinics in Montgomery County.

The views expressed in Physician Voice are those of the author

and not of Suburban Hospital.