Role and Responsibility of the Physician in Palliative and End-of-Life Care: The Interdisciplinary Team Approach

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Role and Responsibility of the Physician in
Palliative and End-of-Life Care The
Interdisciplinary Team Approach

• University of Maryland School of Medicine
• Introduction to Clinical Practice
• Freshman Course

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Why do we need to talk about this?

• Recent national studies indicate that physician
  skills are suboptimal in
• Symptom control
• End-of-life communication

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How we rate on control of pain

• A recent large multi-center survey of patients
  with metastatic cancer and severe pain revealed
  that 42 were NOT GIVEN ADEQUATE PAIN THERAPY!
• Cleeland, et.al., NEJM 330592-6, 1994

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The SUPPORT Study(Study to Understand Prognoses
and Preferences for Outcomes and Risks of
Treatment)JAMA 2741591-1598, 1995

• Objective
• To improve end-of-life decision making and reduce
  the frequency of a mechanically supported,
  painful and prolonged process of dying
• Eligibility...patients at high risk for death
• 50 mortality overall
• Phase I 4301 patients observed
• Phase II randomized, controlled trial of an
  intervention (4804 patients)

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SUPPORT Phase I Results

• 70 of patients or surrogates had no CPR
  discussion with physician...
• Physicians were not aware of their patients
  desire for DNR in 53 of cases
• 50 of patients had moderate to severe pain
  during their last 3 days
• Half the patients spent a week or more in an ICU,
  coma or on a ventillator
• 31 of families lost all or most of their savings
  during the patients final illness

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Main Conclusions of SUPPORT

• too often we die alone, in pain, attached to
  machines
• the system doesnt know when or how to stop
• Prognosis--we often dont know until its too
  late
• when an illness is fatal
• when someone is dying
• may have to accept some ambiguity...

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Suffering in Children with Terminal CancerWolfe,
et.al. NEJM 342326-33, 2000

• Interviewed 103 parents of children who died of
  cancer (1990-97)
• 80 died of progressive disease
• 49 died in the hospital
• 50 of these were in an ICU
• 89 of children suffered a lot or a great
  deal in the last month

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Why dont we do a good job?

• We were never taught in medical school!
• Most schools do not have a comprehensive
  curriculum even now!
• Role of MD in care of dying not defined
• Societal attitudes
• The Culture of Medicine (C. Cassell)

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Traditional Goals ofthe Medical Profession

• To cure SOME
• To relieve OFTEN
• To comfort ALWAYS

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The Culture of Medicine

• Focus on curing
• Public expects miracles
• So does physician
• death of patient viewed as a personal and / or
  professional failure by M.D.
• Perception of medical community
• skills in palliative care are not highly valued

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Just cause the patient is dead is no reason to
stop treating him

• Graffiti on the wall of the staff toilet on Osler
  2, Johns Hopkins Hospital, circa 1974

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We must face the fact that we will eventually
fail with all our patients

• Quote from an attending physic-ian ADVOCATING
  improving terminal care standards

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Chemotherapy and radiation therapy have
failed...What is the role of the physician now?

• We have nothing more to offer ? !

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Palliative Care the treatment of symptoms or
suffering caused by an illness without attempting
to cure the underlying illness

• Usually done when curative therapy is not possible

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What the patient needsfrom the physician

• LEADERSHIP--someone to guide them through the
  process
• PRESENCE
• HONESTY
• INFORMATION

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What is the Physicians role in palliative care

• Effective Communication...
• Timely discussion of disease process, prognosis,
  treatment
• Respect patients choices
• Compassion
• Empathy for patient and family

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Physicians Role in Palliative Care(contd)

• Prognostication
• Symptom Management
• Continual presence

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Physicians role in palliative care (contd)

• Understand the legal and ethical issues

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Hospice Care

• A shift in focus of treatment to intensive
  palliative care
• symptom management
• allows patient to live life to fullest
• addresses emotional / spiritual issues of
  terminal illness
• Interdisciplinary team approach
• Not a place hospice is where the patient is

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What to tell your patients about hospice

• As your physician, I will continue to see you and
  to care for you--
• Our first priority is managing your symptoms
• Services are available at home
• Your family will also receive the support of the
  hospice team
• Hospice care is covered by medicare, medicaid and
  many private insurers...

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The Interdisciplinary Team

• the patient and family
• the DOC
• You
• The Medical Director
• Nurse
• Home health aide
• Chaplain/spiritual advisor
• Social Worker

• Volunteer
• Pharmacist
• Physiotherapist, occupational, speech, music/arts
  therapists
• Dietician
• Janitor....

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How can we make things better?Understand that

• Palliative treatment that allows a dignified and
  gentle death of a terminally ill patient is a
  medical accomplishment of considerable merit, not
  a failure