Reflections on end of life care

I’m only a week into my inpatient solid oncology rotation, but an interesting pattern I’ve observed is a very palpable attitude difference between younger and older generations when confronting end of life care. The advent of palliative care and hospice has caused not only a huge paradigm shift in medicine, but also a shift in society’s views of death. As a physician who has seen death in hospitals, I appreciate how proliferative the media has been in publishing personal anecdotes to (1) inform the public about OPTIONS at the end of life and (2) to increase the level of comfort and awareness people have in discussing death and dying. I appreciate how health care providers have been eager to join in educating people about the dying process. I see younger generations accepting the choice of quality over quantity of life MUCH easier than older generations – perhaps because they are more aware, thanks to media. I’ve noticed in older generations an attitude that reflects how medicine used to be: back when there was still advances to be made, new technology to try out, and treatment was aimed to be aggressive. But, I think the younger generations are realizing that, as medicine has advanced and become more complex, a leap in medical knowledge has also revealed how close we are to the limits of our bodies and our mortality, in fighting  with nature’s inevitable course.

Hospice is an awesome and very much needed advancement in the way we practice medicine. I have confidence that in the next decade, it will be much better established and much better utilized. But, at least right now, every day as a physician I feel its growing pains. As it is still a relatively new idea, tremendous education and advocacy still needs to be done – both on the part of the physician and the ancillary staff. I was happy to see that the New York Times  has a blog aimed to accomplish specifically that, to allow the public access to things we see every day.  I highly recommend perusing their column, “The End”.

One of the articles I would like to highlight is one written by a palliative care physician, on post-home-hospice set up follow up. For all my fellow healthcare providers, especially those who work in the inpatient setting, I think you will find this as humbling as I did. When we spend so much time in the bubble of our controlled, regimented hospital, we can forget about the complexity of caring for loved ones in the real world. Now that home hospice is an option, we get excited when we think we are making patients dignified by sending them to home hospice. And we are, but we can’t forget that EDUCATION is key. This article does a good job highlighting those complexities and issues that can come with information gaps – issues we should always keep in the back of our mind when we talk to patients. After all, we are trying to do the best to accomplish why we send patients to home hospice in the first place – to keep them comfortable, out of the hospital, away from invasive tests that will NOT help them, and instead, potentially cause them more harm and suffering. Without proper guidance, sending people to home hospice means they may very well come straight back, if the family doesn’t properly understand what it means.

Before we shift people off to home hospice and forget about them, here’s a great summarizing quote:

“Fully experiencing the benefits of home hospice requires resources: involved, dedicated family members. Money to afford caregivers, particularly in the absence of involved family members. A neighborhood whose local pharmacy actually stocks opiate medications for severe pain. Insurance that covers stays in nursing homes so that family members can simply be family members instead of caretakers. Without these luxuries, which so many others take for granted, dying at home could actually be less comfortable than dying in the hospital. [We have to realize there is a] wide gap between my idealistic conception of hospice care and the reality of providing it amid life circumstances that shape the circumstances of dying.”

Read more in the original article found here: NYT: Dying at home when you are poor. 

And, in terms of a extremely reasonable option, I like this proprosal : Medicare Part Q?

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