Palliative Care

Wrongful Life

There have been recent discussions in the lay media about a growing trend of litigation cases focused not on the “right to live”, but rather on the “right to die”. These cases have involved patients who received aggressive treatment, despite having documentation of their wishes not to receive such aggressive treatment. Although unsettling, it is not surprising that this issue has arisen, given the national conversations about the exorbitant cost of care at the end of life in the U.S., and the frequency with which patients do not receive end of life care that is concordant with their wishes. These conversations have spurned providers and patients to discuss and document their wishes, via advanced care directives and/or POLST orders (Physicians Orders for Life Sustaining Treatment). There is now even a national day devoted to advanced care decision making (National Healthcare Decisions Day). While these documents are increasingly available for hospitalists…

How Often Do You Ask This (Ineffective) Question?

How often do we get complacent with knowledge?  We hear the same thing over and over, and the message becomes lore.  Drink eight ounces of water per day or turkey makes you drowsy—not only do we as docs believe it but we tell family members and patients the same. I came across a new study in CMAJ that fractures another piece of lore we hold fast. And not only should this study put the kibosh on it, but also upends a practice (a patient question) that teachers from eons past have instructed us to use over and over and over.  The question has intuitive appeal, is easy to gestalt, and has a universal understanding.  Non-physicians and laypeople can grasp what the answer implies without any difficulty.  (more…)

The Best Way to Die?

by David Brabeck, MD, FACP
By David Brabeck, MD, FACP Medicine can be a strange business. Trainees are often thrust into situations involving life and death in which there is often little formal education for end of life experiences. Moreover, relatively few have personally experienced family members or loved ones dying. The population of the United States is aging and palliative care is a growing field. Despite this, formal medical school education regarding palliative care and hospice is quite varied and often inadequate. A recent review in the journal Medical Education reported that medical schools’ curriculums include between two hours and several weeks of training for end-of-life issues. With limited training in this area, residents and supervising attendings are often left to experiential education to guide them in their communication and medical decision making when a patient is close to dying. These can be difficult waters to navigate when futility of care and patient’s wishes…
David Brabeck, MD, FACP is Associate Program Director, Internal Medicine Residency, in the Departments of Hospital Medicine/General Internal Medicine at Lahey Hospital and Medical Center in Burlington, MA. He can be reached at david.m.brabeck@lahey.org.

The Last Days: Cash or Credit?

How often do you hear the following: the average senior utilizes  25% of their lifetime health spend during their last six months of life.  Too much. All that service use in such a concentrated period suggests possibilities. ICUs and inpatient care have great costs.  Our acute and post-acute institutions also do not hold up as models of efficient care delivery.  Most of them at least. What to do? I see the above observations as something akin to an emperor with no clothes. Because leaders with checkbooks have a focus on areas that will generate cost reductions, they seek opportunities they can wrap their arms around.  The more disadvantaged and disjointed ambulatory practices cause too many headaches.  Hospitals then seem like the right place.  Hospitalists and inpatient practitioners seem like the right people. The logic goes, with advanced directives and creative thinking, the right docs and facilities can make a dent…

Reflections on Palliative Care: Uncomfortable

By: Dr. Allison Schneider Throughout my Palliative Care rotation during this last year of medical school at UCSF, I began turning to writing as a way to both process and remember some of my patients and the intimate moments we shared. This is the second pair of poems I’ve written as a small way to pay tribute to them. (For the first installment in the series, click here.) Uncomfortable Where is your pain? Everywhere. Please give me something. I just want to sleep. It’s okay not to fight anymore. Thank you. But will he wake up? My kids are in school. They'll be here at five. Can you be here? Thank you. Thank you so much. Mr. L, metastatic nasopharyngeal carcinoma, age 49 45 Liters I led 1000 men into battle. Most of them didn't make it to 93. Isn't that right, Bruce? It's been a good life. So can I go…
Dr. Allison Schneider grew up in Washington, D.C., and received a BA in Public Policy and American Institutions from Brown University. She then worked for the Kaiser Family Foundation Commission on Medicaid and the Uninsured prior to entering medical school at the University of California, San Francisco. She graduated this month and will be starting her residency training in Obstetrics and Gynecology at Kaiser Oakland Medical Center in July.