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Demystifying Medicine One Week at a Time

Fundamental Question

Every once in awhile amidst the weekly deluge of medical articles comes a show-stopper that has the potential to change the way we practice.

Rarer yet is the article that not only changes how we practice, but calls into question why we do what we do.

This recentĀ article from the New England Journal of Medicine is just such an article. Before you bolt, let me simplify it for you.

Find your peaceful place

Here’s the quick take:

The authors enrolled 150 patients with advanced lung cancer and split them up between usual care, which included chemotherapy, and an intervention arm, in which they received the same standard of care treatmentĀ plus early enrollment in palliative care.

Now lung cancer, mind you, is one of the bad ones. By the time it’s advanced, i.e. spread either across the chest or elsewhere into a different part of the body (“metastasis”), the prognosis is poor. Survival is less than one year, on average. (Hey! Didn’t I just read a recent article on why doctors are so bad at predicting survival?)

Palliative care is medical care that treats for patient comfort foremost, and does not seek to cure the underlying chronic illness, be it cancer or other advanced disease, like congestive heart failure or emphysema.

It’s often confused with hospice, which is the level of care (or physical place) for patients with a less than 6 month prognosis. Hospice usually involves being less aggressive with the medical care, while palliative care aggressively seeks comfort for the patient, sometimes involving complex treatment. The confusion comes because palliative care is not mutually exclusive to hospice (indeed, they often overlap), nor is it mutually exclusive with standard disease treatment, as evidenced in this article. Cure and comfort can both be vigorously pursued.

In fact, one reason why palliative care gets invoked so infrequently is that families and medical folks often conflate palliation with hospice.

The study results were, in some ways, not so surprising: The patients that received early palliative care along with their cancer treatment had lower self-reported scores for depression and anxiety, and higher scores on “quality of life” scales. [Don’t stop the presses. This proves the obvious.]

But surprisingly, the group that received palliative care early survived longer. An average of about two months longer. Not so much, you say. But mathematically, more than 25% longer. Remember, average survival in advanced lung cancer is about a year. When you’re talking survival in months, an extra two months is a lot: more grandkids, more valedictories, more closure, more goodbyes; maybe even more off the bucket list.

And this was achieved without more chemotherapy. Just more contact (on average, 4 visits to palliative care). And more addressing of symptoms.

Isn’t providing comfort and symptom control why we went into medicine in the first place?

Sometimes doing less in the way of fighting for a cure offers more in terms of meaning. And as this study shows, more of life itself….

4 Comments

  1. Bohdan A Oryshkevich, MD, MPH

    October 2, 2010 at 11:39 pm

    Amen!!!!

    Bohdan A. Oryshkevich, MD, MPH

  2. Reading this reminds me that my mother was being visited by a hospice nurse while I took care of her in her final days. For some reason, she had a supply of anti-depressants. They ran out. Hospice would not provide any (she had gotten them God knows where – not from hospice, which was fine with her morphine). She died not long after running out of those pills. I grieve her death, but I REALLY grieve the mistake of not supplying her somehow with anti-depressants, come hell or high water.

  3. Awesome post, John.

  4. This is, by far, the absolute BEST description of the differences between palliative and hospice that I have EVER read. I would love, if you don’t mind, like to reblog this on my blog. I lost my mom to lung cancer in May 2012 and she actually lived much longer than any doctor had PREDICTED. She was diagnosed in Sept of 2008 and for the first three years she thrived because she had a GREAT mental attitude and in her mind she just knew that she was going to be lung cancer. That attitude waned as the physical and real aspects of lung cancer took hold and the brain mets began to alter her state of mind. She was a teacher and guidance counselor and she couldn’t understand what was happening to her.

    However, the last six months of her life were more emotionally draining for her (and the family) than it was physically. She had hospice care (after she fought it) and individually the nurses and staff were great. But, they were limited in the services they could provide and mom needed pychosocial services. She was scared and confused and really didn’t understand how or why she declined so rapidly the last few months of her life. Her doctors pretty much said there was nothing else they could do for her. So what does one do for the last supposedly six months of their life?? She needed someone to TALK to her, to tell her she wasn’t crazy, to make her laugh. The hospice staff had a social worker, but there was only one and that person only came by once a month. And then towards the end, the social worker left and they had not hired another one. I did what I could do.

    I wish I could have done more. Her doc introduced palliative care to us in the same sentence as hospice. I wish I had known then what I know now. This article convinces me even more that I did the right thing leaving my 20-year career to pursue a career in healthcare admin. WE have GOT to do better.

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