Palliative Care: Something We All Want

As a hospice physician – in addition to my role as a doctor who treats cancer – much of my focus is on comfort care. Part of my motivation to study medicine stems from my childhood concept of who a physician was and should be: a healer and comforter. The physician of yesteryear came to the bedside to care for and comfort the sick (and yes, the dying). I love that the Latin root for comforter is confortare, meaning, “to strengthen much.” In Christianity, the Holy Spirit is also called the Comforter.

Frankly, all physicians should practice comfort care. We know we aren’t to harm our patients. That obligation not to inflict harm intentionally is the ethical principle of nonmaleficence. It is summed up in the Latin phrase Primum non nocere – First, do no harm. The Hippocratic Oath states, in part, “I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing.” That oath – to help the sick – expresses our obligation to do good (the ethical principle of beneficence). Though the actual oath used in various medical schools has changed over time, the overarching mandate to help the sick – and, at a minimum, not to harm them – is universal.

What does it mean to help the sick? That seems, on the surface, like an obvious question. “To cure, of course!” we would say in the 21st century. But curing disease is a quite modern concept. For most of medical history, comfort care was the primary goal. Modern technology and the emphasis on cure got us advanced cardiac care, open heart surgery, amazing innovations in cancer treatment, and so much more. But by 1980, most people died in the hospital. This was rare just a generation or two prior to that, when nearly everyone died at home (or on the battlefield). 

Since 1980, the number of people dying in the hospital has declined somewhat, thanks in part to better end of life care (including hospice care). However, 7 out of 10 Americans still die in a hospital, nursing home or long-term care facility when 7 out of 10 of us say we want to die at home (only 25% of Americans actually do die at home). Utilization of hospice care at the end of life is still woefully low.

But, what about those in the hospital who aren’t expected to die, who want a better, more “comfortable” hospital care experience overall? “Cure sometimes, treat often, comfort always,” is a wonderful mantra attributed to the 19th century tuberculosis physician Dr. Edward Trudeau. This phrase sums up a newer movement in medicine called palliative care. 

Palliative care focuses on preventing and relieving suffering and on supporting the best possible quality of life for patients and their families facing any serious illness. To palliate means to relieve – literally, to cloak – with the focus being on symptoms. Symptom management obviously should not be limited to end of life care.

As an example, for an ICU patient suffering from an acute exacerbation of lung disease, probably on a ventilator for a short period of time (but expected to recover), the physician historically has been paying attention to oxygen and carbon dioxide measurements, volumes of air going in and out, the acidity of the blood, and other “numbers” that paint a picture of how the patient is doing. But not how the patient or family is feeling. Shortness of breath? Anxiety? Nausea? Pain? Dealing with prognosis and potential end-of-life decision-making? Social and spiritual support? These are issues that might benefit from a palliative care consult.

Every hospitalization (whether ICU or not) has the potential for needing some degree of palliative, or comfort, care in addition to and alongside the acute medical needs that precipitated the admission in the first place. Often, the treating physician can and should address these needs. Quality metrics such as patient satisfaction, length of stay, and even cost of hospitalization are improved with good symptom management.

And, believe it or not, sometimes patients live longer with good comfort care! In my field of oncology, randomized trials have shown improved quality of life and even improved survival with early use of palliative care. The American Society of Clinical Oncology (ASCO) recommends the integration of palliative care with conventional oncology treatment, and the American Society for Radiation Oncology (ASTRO) has urged early palliative care referral when cure is not expected, even if death is not imminent and treatment still is ongoing.

CHI St. Luke’s Health Memorial in Lufkin will be starting a new palliative care consult service later this fall. A team consisting of a physician, nurse, and social worker all certified in palliative care will be available to consult with and advise physicians on any patient with difficult to manage symptoms, regardless of whether or not the patient has a terminal prognosis.

As we learn more about palliative care, we remember the Golden Rule: “So in everything, do to others what you would have them do to you, for this sums up the Law and the Prophets (Matthew 7:12, NIV).” 

Comfort always.

Choosing Wisely

My specialty society, the American Society for Radiation Oncology (ASTRO for short) is a participant of Choosing Wisely®, an effort to support and engage physicians in being better stewards of finite health care resources. The goal is to identify commonly ordered procedures or treatments that not only may not be necessary but, in fact, may be harmful. Each participating specialty provides five such procedures they believe are over-utilized or inappropriately ordered.

I was struck by two of these treatments in particular, the first because of its technological "sophistication" and the second because it points to new standard of care.

The "sophisticated" procedure is proton therapy. Unfortunately, the "new" in medicine is often assumed to be the "best". After all, technology only improves our lives, right? Sometimes investors are too cozy with equipment manufacturers who then get the federal government to reimburse a technology well before that technology has been proven to be any more effective than what is currently available.

In the case of proton therapy, investors saw a way to make a LOT of money, because proton therapy was originally being reimbursed at more than six times the rate of standard radiation therapy ($850 per daily proton treatment versus $132 for standard radiation treatment). Proton installations cost tens of millions of dollars to install. MD Anderson's cost $125 million when it was built in 2006. The Houston Police Officers' Pension System was one large backer ($10 million) expecting a sizeable return on their investment.

ASTRO, in a bold move that was sure to ruffle the feathers of some of its profit-minded members, announced last week at our meeting in Atlanta that one of its Choosing Wisely® recommendations is: "Don't routinely recommend proton beam therapy for prostate cancer outside a prospective clinical trial or registry." Their reason? After seven years of proton profit in the marketplace, "There is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy."

Bravo. I have bemoaned for years the grab for the money that goes on in medicine, and how that leaves the poor and under- or uninsured with even fewer healthcare resources, as these expensive technologies are, for the most part, only available to those with means to pay for them. I am proud that the House of Medicine is taking steps to control healthcare costs by pointing out our own dirty laundry. Let's hope these recommendations are taken to heart. (I'm not holding my breath.)

The second recommendation is far more positive, and will be a game changer in my specialty: "Don't initiate whole breast radiotherapy as a part of breast conservation therapy in women age >50 with early stage invasive breast cancer without considering shorter treatment schedules." A just-released important study concluded that a particular treatment schedule common in Europe is equivalent to a longer schedule of treatment that we use in the US, and that long term side effects are less! The benefit for women is that a typical course of treatment will be reduced from 5-6 1/2 weeks down to 3-4 weeks. For women who have to travel longer distances to get in for treatment, this can be significant. In addition, it is less expensive. Again, Bravo.

Healthcare is, indeed changing. I have given you two examples of change - one negative, one positive. Educate yourself, and choose wisely.

For information on Choosing Wisely® and recommendations across medical specialties, visit www.choosingwisely.org. Do your part to help cure cancer; enroll in CPS-3 at www.CancerStudyTX.org.