Cell 2 Soul: The Humane Health Care Blog

What Matters in the End

Krista Tippet’s conversation with Atul Gawande

You can listen to this extraordinary interview on the podcast On Being. It lasts about 50 minutes and addresses some of what Gawande addresses in his book “Being Mortal.“

Here are some highlights:

At medicine’s core is the directive that all people deserve the same type of attention by practitioners. Of course, this doesn’t happen. Our biases prevent this.

What does it mean to be a good doctor one for a given patient when you can’t help to fix them? How do you feel and what do you do when you actually have harmed a patient?

With regards to our patients, how can we give them agency to live a good life to the end? That may mean not promoting painful, expensive fruitless therapies.

Medicines goal is really to support a patient’s well-being. This can often mean that the patient will direct her own life.

One can actually ask a patient “What does a good day for you look like? What is the quality of life that you live for? Quality of life should not always be sacrificed for quantity of life.

A 2010 study* from MGH show that those stage four lung cancer patients who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives – and they lived an average of 25% longer. In other words, our decision-making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality.

So it’s important to find out what our patients goals are. Susan Block, a palliative care specialist, told him: "A family meeting is a procedure, and it requires no less skill and performing in operation."

A few years ago, I put some notes on Gawande’s book on Google Documents.

*Jennifer S Temel et. al. Early Palliative Care for Patients With Metastatic Non-Small-Cell Lung Cancer. NEJM , 363 (8), 733-42, 2010 Free Full Text

Music Therapy Offers an End-of-Life Grace Note

by Sharon Ottermanjian NY Times, Jan. 15, 201

Music therapy, a board certified health profession that has about 7,500 practitioners nationwide, is becoming more prevalent in nursing homes and hospices because of sessions like those reported in this article. It is increasing being used in end-of-life care.

Russell Hilliard, the founder of the Center for Music Therapy in End of Life Care in Finksburg, Md., has published research showing that in the hospice environment, music therapists were often the only professionals consistently treating emotional, spiritual, cognitive, social and physical needs of patients.

While it has not been proven to extend life, multiple studies have shown music therapy can improve quality of life, inspire feelings of peace, spirituality and hope, and reduce pain.

Comment: This is an example of low-tech high value care that improves patients' well-being and is associated with no untoward side-effects.

Palliative Care

by Brian Maurer

In autumn splendor
The dying leaves drift down
To cloak the dead,
While overhead
The hunter’s moon casts
Her misty shroud
On fallow autumn fields.

About Brian T. Maurer.  Brian is a pediatric physician assistant, an essayist and a poet.  To see his blog and learn more about his work go to Brian T Maurer's Web Blog.

My Mother-in-Law’s One High Day

When my mother-in-law was in the final, harrowing throes of pancreatic cancer, she had only one good day, and that was the day she smoked pot.  Read this thoughtful, sad piece from the NY Times Journal of Medicine (12/10/11).

Marginal Notes: El Tío Nayo

We enter the narrow winding cobblestone streets of the port of Cariño and weave our way up the inclines past the fountain in the small plaza. Up above, at the cemetery, the vista opens up. From here you can look down on the red-tiled roofs of the town past the ancient stone wharf across the bay to the Isle of San Vincente and the large expanse of white beach beyond. Off to the left, away to the northeast, the jagged coastline stretches all the way to the punta of Estaca de Bares, the northern most point of Spain. >>more 

Brian T. Maurer has practiced pediatrics as a Physician Assistant for thirty years.  His "Marginal Notes" column appears periodically in the Cell2Soul Blog. The title "Marginal Notes" is taken from a quote by Henry David Thoreau: "I love a broad margin to my life."

Marginal Notes: Web and Flow

While toweling off after my shower, I noticed a grey spider descending from the light above the bathroom sink. Her spinnerets formed a nearly invisible silken thread as she dropped down to hang motionless before the mirror. Shortly, she retreated up to the light and selected another point from which to begin a new descent. This time she dropped down to the shelf below the mirror and crawled behind my toothbrush. Gingerly, I nudged it to the side to reveal the spider resting by a tiny puddle of water.  >>more

 

Brian T. Maurer has practiced pediatrics as a Physician Assistant for thirty years.  His "Marginal Notes" column appears periodically in the Cell2Soul Blog. The title "Marginal Notes" is taken from a quote by Henry David Thoreau: "I love a broad margin to my life."

Marginal Notes: A Life or Death Decision

Technology can be a curse. If we didn’t have ET tubes and ventilators, life would take its natural course. We have created our own demons, and they constantly come back to taunt us: in this case, six additional months of ventilator dependence, dialysis and a feeding tube before death from heart failure. >>more

Brian T. Maurer has practiced pediatrics as a Physician Assistant for thirty years.  His "Marginal Notes" column appears periodically in the Cell2Soul Blog. The title "Marginal Notes" is taken from a quote by Henry David Thoreau: "I love a broad margin to my life."

Engage with Grace

"The One Slide Project was designed to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it.  We're asking people to share this One Slide – wherever and whenever they can… Just One Slide, just five questions to get us talking."

This is an important, well-conceived project.  For more information go to web site:

Assisted Suicide

Two fine pieces appeared on this topic in today's NY Times:

Keeping a Promise When a Life Is Near Its End
By ELLEN D. FELD, M.D
A  mother’s request to her daughter for “help” if something should happen to her is agonized over, accepted and eventually fulfilled.

Landscape Evolves for Assisted Suicide
by Jane Gross
"Washington joined Oregon last week as the second state where physicians are allowed to prescribe lethal doses of medication to terminally ill people who want to hasten their own deaths. But the question of whether doctors should help patients die is far more nuanced than it was 11 years ago, when the Oregon measure took effect."

Pain

Emily Dickinson said it best:

After great pain a formal feeling comes--
The nerves sit ceremonious like tombs;
The stiff Heart questions--was it He that bore?
And yesterday--or centuries before?
The feet, mechanical, go round
A wooden way
Of ground, or air, or ought,
Regardless grown,
A quartz contentment, like a stone.

This is the hour of lead
Remembered if outlived,
As freezing persons recollect the snow--
First chill, then stupor, then the letting go.

The subject of pain and pain control is a huge one -- suitable for textbooks not blog entries.  However, we would like to bring to your attention two recent articles from the NY Times which address this topic.  It is shameful that opioids are not available  to the majority of the world's population considering they are safe and cheap.

1. Drugs Banned, Many of World’s Poor Suffer in Pain  September 10, 2007

2. Japanese Slowly Shedding Their Misgivings About the Use of Painkilling Drugs Sept. 10, 2007

3. In India, a Quest to Ease the Pain of the Dying September 11, 2007

4. Francis W. Peabody wrote a classic piece "Notes on the Effects of Morphine" in 1927.  It was completed shortly before he died of stomach cancer and while he was relying on opioids so he could function.  Here it is for those who are interested: Download peabody_on_morphine.pdf