MGordon_MD
User
/ Moderator
Feb 8, 2010, 1:37 PM
Post #1 of 1
(8322 views)
Shortcut
|
By Dr. Michael Gordon
It happened again. I was called by one of the palliative-care physicians I work with who told me about a patient who had been admitted for palliative care because of metastatic (spread) cancer, and suddenly “took a turn for the worse.”
As a result, the family had unexpectedly asked that she be transferred to an acute-care hospital, where she received complex and intensive medical care for an inter-current medical event.
I asked whether the family understood the implications of their loved one’s admission to a palliative-care unit. The physician felt that the request for acute care showed that the family did not understand what was going on, as the cancer had spread. His question was: “Why the change of heart and direction of care?”
As I and members of the staff looked back over the last year, we could identify a number of situations in which, at the “last minute” or so, it seemed a family – acting as surrogate decision-makers – changed their minds about the previously agreed-to principles of palliative care and had their loved one sent to an acute-care hospital.
Most of the patients died in the hospital after a period of attempted treatment. Some had a condition, such as an inter-current infection, treated, and they returned to the palliative unit where they died, sometimes shortly after the episode and sometimes a period after. No one can discount any period of time alive, depending on the values and goals of the patient and family, when faced with a disease from which death is expected to occur in the near future.
The philosophy that underpins the concept of palliative care, sometimes referred to as “terminal care” or “hospice care,” is an amalgamation of different concepts, the place and type of care (palliative-care unit and hospice) and the stage of a disease.
Patients and families often want a prognosis from their physicians, to give them some idea about what to expect in the future and what kind of planning to undertake. This is very important when people have to consider when family members should perhaps travel, especially if long distances are involved. Many family members want to be present in the “final” days, especially when they may want to combine a long-distance visit to say goodbye and to be at the funeral.
The problem with prognostication is that physicians, no matter how experienced, can be off by a great deal in predictions of the course of even the terminal phases of a disease. Part of the palliative care discussions should not just include a prognosticative estimate but should always contain the provision that many unexpected things can happen, often with little warning. Sudden “turns for the worse” and death occur often enough that families should be prepared for such events.
Maybe for some families, as Dylan Thomas expressed in his well-know poem, elders should “not go gentle into that good night/ Old age should burn and rave at close of day/ Rage, rage against the dying of the light.” What this might mean in medical practice is that rather than dying in comfort as the goal at the end of life, the family chooses a course that might result in intubation and respirator care, intravenous treatments and a whole range of medical interventions.
These might provide some benefit for some undefined period of time. Maybe that is the modern way of “raging against the dying of the light.”
---
Dr. Michael Gordon is Medical Program Director, Palliative Care Baycrest Geriatric Health Care System in Toronto, Canada and Professor of Medicine, at the University of Toronto.
Dr. Gordon is the author of the engaging memoir Brooklyn Beginnings: A Geriatrician's Odyssey, published by I-Universe.
Brooklyn Beginnings is available in bookstores and online at: Indigo-Chapters, Amazon.ca, Amazon.com, Barnes and Noble and I-Universe
Moments That Matter: Cases in Ethical Eldercare: A Guide for Family Members, is available online at Amazon.ca.
His latest release is Late-Stage Dementia: providing comfort, compassion and care. It is available at Amazon and Indigo.
Visit Dr. Michael Gordon's website.
(This post was edited by MGordon_MD on Mar 22, 2010, 7:59 AM)
|
MAIN
SEARCH
WHO'S 
LOG 