Wednesday, August 12, 2009

"End-Of-Life Issues" Aren't The Bogeyman

As scary or creepy or welcome as we may find the prospect of our own death, or the deaths of our dearest family and friends, the one inescapable fact is -- we all die. Whether your life span is a brief day or as long as a bristlecone pine's, you have a one-way ticket to ride, and when your stop comes up, off you go.

I discussed some personal reflections on the subject HERE, but this post takes a different tack.

In my medical work, I see oncology and vascular surgery patients who, day by day, live with the imminence of their own personal death. To them it's not some day in the foggy future when a plane might go down, a gun is aimed the wrong way or a car accident sends them into the blue beyond.

"The" day is maybe months but more likely just weeks away -- sometimes as near as the next dawn.

Doctors who treat these patients through their last illness routinely have lengthy discussions with them and their families, and even close friends, -- not about taking a little pill that will end it all with an icy cold glass of water -- but about how those last few weeks should be medically managed from the patients' and concerned loved ones' perspectives.

If the illness has progressed despite available treatments, if there truly is no hope left to hang onto, if the "next step" would be so drastic as to involve extreme, unreasonable measures, then it's time to consider pain control, hospice care, family travel arrangements, palliative care that might involve minor surgical procedures for comfort only, not cure. These are the real "end-of-life issues." The practical matters that matter so much for those dying and those who will hold the last days in their memory.

Doctors who treat patients with diseases that have a natural history of incurability seem to me to be very sensitive in the way they handle these terrifying and final subjects with their patients. In my experience, they are willing to investigate the latest treatments, to enroll their patients in clinical trials, to use medications "off label", to refer the terminal patient to a tertiary care center or a well-known physician with an exceptional record of succss -- all in the hopes that there will be a prolongation of life.

Physicians are also realists. They know, and they are conscientious in advising the patient and family over and over, what that patient will inevitably be facing, and when.

In each case I've seen, (including even patients who are demented or otherwise have no real "life" such as you and I might recognize it), doctors are extremely cautious to not suggest cessation of treatment before all reasonable avenues have been exhausted.

The truly desperate will sometimes run to Europe or Mexico for a "miracle cure" but, again in my experience, most people who have reached the terminal stage of their disease know it - realize it - and very often have made peace with it. The "end-of-life issues" discussion is about practical care issues, not assisted or encouraged suicide.

In the 15 years that I've been working in this field, I've seen a few obvious mistakes, a dollop of temper and gallons of ego, but I've also seen unwavering sincere care and admirable ethics, particularly by doctors who handle terminal patients frequently by the nature of their specialty.

I saw something today, somewhere on the internet, that this is a discussion you should have 20 years before the time you need it. Maybe so, if you're talking about an advance directive, people making care decisions for you, or wills and trusts and other legal issues.

But the true end-of-life issues don't arise until truly the end of life. You've been battling a terminal condition for weeks, months, years, the treatments are no longer working, the disease is progressing -- how would YOU prefer your final days to be managed?

Wary people, who already fear government's involvement in health care, have latched onto this "end-of-life issues" phrase and have created a bogeyman for no reason. These discussions are held every day now and are done with kindness, concern and pragmatism.

It may be the one thing about Obamacare that doesn't scare me, and from my experience, it shouldn't scare you, either.

1 comment:

Hospice California said...

This article reinforces that concept with some practical advice.Thanks for your valuable support.

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