Saturday, December 24, 2011

Rotation in Palliative Care

This month, I decided to do a rotation in palliative care and already I'm wondering what on earth I've gotten myself into. The training is very valuable, but the process can be heart breaking. The Palliative Care Team that I am working with is extremely compassionate toward end of life care. I am learning all kinds of techniques for speaking with families and providing comfort measures. It is important to me that I learn these skills so I can give comfort and support to my own patients some day. If I had my preference, my patients would just live forever.

My first patient on the first day of the rotation was a patient who is my age. This patient is suffering from advanced lymphoma which is complicated by an intracranial bleed. They have been married for about as long as Matt and I have been married. I couldn't help but think about my husband when I was speaking to the patient’s family. It was difficult for me to look at the family without thinking of how tragic it would be to lose my own spouse. I had trouble keeping the tears back and it took every ounce of professionalism I could muster to hold it together. It's so difficult when patients remind you of your own loved ones, but I find that more often than not I begin making these associations.

The patient had been on comfort care measures only, but a new oncologist on the service had some hope for a palliative treatment that might improve the patient's neurological status. It would involve weekly intrathecal chemotherapy. The oncology team had good intentions. They were invested in saving the life of the patient. We are all trained from the beginning of medical school that the goal is to save lives. Death equals failure, but is ultimately unavoidable. Now the family is torn between keeping their loved one comfortable and doing everything medically possible to extend their life. There is no right decision.

According to family members, this patient is a fighter and has expressed his wishes to fight the disease until his death. Following this logic, should we do everything medically possible? Where is the endpoint? At what point do we cross the line of "do no harm" while using heroic measures to save the patients? Is the Palliative care team correct in their philosophy of comfort care measures or are the oncologist’s efforts more appropriate? I'm not sure any of us have the answer. It's a judgment call.

After reflecting on this case, I think the important thing for this patient was to keep the patient comfortable while doing everything possible to treat his cancer so the family can be at peace with the efforts to help their loved one. It is important that we don’t force our own beliefs on those that trust us in the end. The death process is very individual. The patient's wishes should be at the forefront of our thoughts when we are making treatment decisions. My own opinion is shaped and formed by my experience with the death of my father. He was also a “fighter” and wanted to treat his multiple myeloma until the very end. He taught me that some people value quantity of time over the medical profession’s judgement of quality of life and this must be considered if we want our patients to face their death with dignity and peace. I still have a lot to learn when it comes to ethics in medicine and I encourage people to respond with their own advice and opinions on this topic.