Tuesday, August 19, 2014

Dying Peace

By Johnson Wu, DO
Austin Family Medicine Resident

A recent CBC News story showcased a research study conducted by Harvard Medical School and Cornell Medical College that examined what happens to patients who received palliative chemotherapy. Palliative chemotherapy is the use of medications for cancer patients to ease symptoms and prolong survival but not to cure their disease. The study showed that 68 percent of patients who received palliative chemotherapy died in the place they wanted; within this group, 47 percent died at home. By contrast, 80 percent of patients who did not receive palliative chemotherapy died in the place they wished, and among these patients, 66 percent died at home. Unfortunately, patients who received palliative chemotherapy were less likely to realize their illness was terminal and less likely to discuss end-of-life care with their families and physicians.

Patients and families face the terribly difficult question of what to do after being diagnosed with a progressive cancer. Based on the numerous slogans and war cries to “win the fight” and “beat cancer,” it's not surprising that many patients and families opt for chemotherapy, radiation, and surgery. Sadly, it’s not uncommon for patients to misunderstand the effectiveness of chemotherapy on some of the most common and deadliest types of cancer. A 2012 publication in the New England Journal of Medicine (NEJM) reported that 69 percent of patients with lung cancer and 81 percent with colorectal cancer did not report understanding that chemotherapy was not at all likely to cure their cancer.

As a newly graduated physician, I have already seen my fair share of patients who received aggressive therapy at the end of life. Most recently, I followed a 92-year-old patient who underwent surgery to remove a stomach tumor. She ultimately spent her last two months of life in the hospital with a tube placed through her nose into what remained of her stomach, suffering from severe abdominal pain and intractable nausea and vomiting until the day she died. She is a prime example of the consequences of aggressive care at the end of life.

My hope is to see every person treated with respect, dignity, and without suffering at the end of life. We can do this only if we as a society are open and willing to accept comfort care and quality of life over aggressive treatment. This is directed not only to patients receiving care but also to the physicians who provide that care. Death is inevitable, but patients should be able to die in peace.

In 2006, the Board of Medical Specialties officially recognized hospice and palliative medicine. Its main goals are the treatment of symptoms, relief of suffering, and end-of-life care. Hospice care specifically applies to those patients who are estimated to have six months left to live, while palliative care encompasses all patients with life-limiting or serious disease. Though the subspecialty was formed less than a decade ago, physicians have always practiced palliative care. Historically, most palliative care has been offered by a patient’s primary care physician.

When a patient decides to refuse treatments aimed at curing disease or extending life, it should not be viewed as “giving up.” Rather, we should look at this in a positive light, a choice to accept quality of life over unneeded pain and suffering. Interestingly, for certain cancers, another article in the NEJM has shown that early palliative care not only provides significant improvement in quality of life and mood, but also can actually help patients live longer when compared with aggressive care.

In the face of an aggressive cancer with low cure rates, it is understandably difficult for patients to decide between treatment and comfort care. The treatments that are toxic to cancer are also toxic to the body and can cause significant side effects such as pain, infection, memory loss, nausea/vomiting, and bleeding.

At the end of life, I urge everyone to consider this for themselves and their loved ones: Do we want to spend our last days tethered to machines and as victims to suffering caused by chemotherapy, radiation, and surgery? Or would we rather be amidst our loved ones, in a comforting place, with medications to ease our pain?

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