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Providing
Care, When the Cure Is Out of Reach
By
Jane E. Brody, the
The day of reckoning for Dr. Diane E. Meier, a geriatrician at "What's going on here?" Dr. Meier
asked the resident on duty. "This man is dying. Why is he tied to the
bed?" He'll die if I take out the tube, the
resident replied. "A light bulb went off in my
head," Dr. Meier recalled. "This is not a bad doctor or an evil
doctor. He just doesn't know what to do." And so in 1997 a new service was born at The program Dr. Meier directs, the Lilian
and Benjamin Hertzberg Palliative Care Institute, is not a hospice, though
it shares the same philosophy of care. Unlike hospice, it is not limited
to patients who are expected to die within six months and who are
generally required to relinquish insurance coverage for treatment aimed at
a cure or prolonging life. "Palliative care applies to any patient
at any age, regardless of whether they are expected to die or
recover," Dr. Meier said. Millions of Americans, she added, are now
living with multiple chronic illnesses for years before they die:
"dementia, heart disease, chronic lung disease, cancer, frailty, and
it is not possible to say they'll be dead in six months." "If palliative care is dependent on the
ability to predict the time of death," she continued, "it means
most people won't get it. We need to uncouple palliative care from death
and dying. Every patient needs this kind of care. The patient does not
have to be in the throes of terminal illness and does not have to forgo
life-prolonging treatment. Palliative care is optimal medical care for
sick people, whether they will live for 10 days or 10 years." Palliative care has arrived at a time when
chronic diseases like congestive heart failure and long-term illness like
many cancers and Alzheimer's disease are on a meteoric rise, taxing
families and doctors. Some 1,500 hospitals now have palliative
care teams, up from fewer than 100 just five years ago. Among medical
schools, 87 percent now require instruction in the treatment, up from 25
percent in 1997. But while doctors may be learning about the existence and
value of palliative care, few have the time, expertise and communication
skills needed to provide it, Dr. Meier said. Patients and their families routinely
express their gratitude for the attention given to the physical and
emotional comforts of their loved ones, Dr. Meier said. Doctors, who
rarely have more than a few minutes to attend to the very sick, are
grateful when they see that their patients eat better, sleep better and
are better able to complete a course of therapy, she added. And patients receiving such care save
hospitals money, Dr. Meier added. These patients are less likely to
require very costly treatments and more likely to spend fewer days in the
hospital. Dr. Meier tells of a 50-year-old man who was
slowly dying of multiple causes, including a very stubborn infection being
treated intravenously with a potent antibiotic that cost hundreds of
dollars a day. The powerful drug had knocked out healthy micro-organisms
in his gut and left him with severe intractable diarrhea. The palliative care team recommended that
the antibiotic be stopped, reversing the diarrhea. The man was far more
comfortable, as were his family members, who were with him through his
remaining days. "More is not necessarily better,"
Dr. Meier said. "More is sometimes worse, but it is often hard for
physicians to see beyond what they believe they must do, which in this
case was cure the infection." One goal, she explained, "is the
rational use of effective, scarce hospital resources applied to patients
who can benefit from them, not to those who will be harmed." "When patients and families understand
the choices," she continued, "they are better able to consider
what they want to do with the time remaining. Very often, the family
decides they want to take the patient home." When her program
started, 90 percent of its patients died in the hospital. Now 50 percent
go home with practical support, coordination of care and symptom relief. While a doctor bent on a cure may tell
someone with an incurable disease that "there's nothing more we can
do," Dr. Meier said that "the sicker a patient is and the closer
to the end of life, the more you can do." "Too many doctors have been trained to
think that if they can't provide a cure, they have nothing to offer,"
she said. She tells of a 24-year-old woman with acute
leukemia whose goal from Day 1 was cure. But unfortunately her cancer did
not respond to treatment. "The woman was very weak, in extreme
pain, very anxious, short of breath, anorexic and unable to sleep,"
Dr. Meier said. "But because she continually asked for more pain
medication before she was scheduled to receive it, she was blamed as a
drug seeker." The palliative care team quickly established
that the woman was seriously undermedicated for pain and had other needs
that could be met to make her more comfortable. The growing demand for palliative care
services testifies to its value. In the first year of Dr. Meier's program,
50 doctors asked for consultations for 200 patients. Now the team gets
referrals from 800 doctors. Her program, staffed by three full-time
nurses, one full-time social worker and one full-time attending physician,
works with physical therapists, occupational therapists, chaplains and
others. "Our team is much bigger than what we pay for," Dr.
Meier said proudly. "A single doctor can't do it." Still, a major stumbling block to the growth
of palliative care has been finances. For example, the Dr. Meier explained: "We operate with a
diversified portfolio of support from the hospital, philanthropic
organizations, grateful families, foundations and government grants. The
services we can bill for cover just one salary." Copyright
© 2002 Global Action on Aging |
