Tagged: Death

May 6, 2013

Unreasonable optimism among physicians common during end of life care

Unreasonable optimism among physicians negatively impacts patients’ end of life care- often influencing the terminally ill to accept more aggressive, costly treatments with little chance of effectiveness.

Haider Javed Warraich, a resident of internal medicine at the Beth Israel Deaconess Medical Center, recounts his optimism when he first met a woman suffering from heart failure and a condition preventing blood from flowing out of her heart.

“While learning her medical history, I also got to know her,” Warraich writes. His patient was a 50 year-old former artist, derailed by addiction. “At this point, she wasn’t a suitable candidate for heart surgery. But I felt there was still hope,” he recounts in The New York Times Sunday Review.

With perseverance, Warraich convinced his colleagues to order a procedure called alcohol septal ablation. Though the procedure could potentially reduce her symptoms, it came with many risks. His patient died the next day, after a complete heart block and aggressive attempts to revive her.

Warraich explains that he was victim of “irrational optimism, a condition running rampant in both doctors and patients, particularly in end of life care.” These physicians may push for costly and more aggressive treatments as a last resort, even when there is little hope of recovery.

As a study published in 2000 for the British Medical Journal shows, about two-thirds of doctors overestimate the survival of terminally ill patients. ”Doctors are inaccurate in their prognoses for terminally ill patients and the error is systematically optimistic,” concluded the researchers, headed by Nicholas A. Christakis, then of the University of Chicago.

Many times, those poor estimates are never fully communicated to the patient. A 2001 study of cancer patients published in the Annals of Internal Medicine found that physicians only told patients their estimated survival 37 percent of the time. No estimate was given 23 percent of the time. “Around 70 percent of the discrepant estimates were overly optimistic,” Warraich notes.

A 2012 study published in the Journal of Clinical Oncology found that cancer patients who talk with their physicians about how they want to die are less likely to opt for aggressive end of life treatments in the last two weeks of life, and they have much more comfortable deaths.

“Aggressive care at the end of life for individual patients isn’t necessarily bad, it’s just that most patients who recognize they’re dying don’t want to receive that kind of care,” said lead author Dr. Jennifer Mack of Harvard University Medical School.

Similarly, Warraich suggests more palliative care for patients unlikely to survive a serious illness. “Modern palliative care originated in response to the proliferation of new treatments and resuscitation technologies,” he writes. Palliative care not only provides more comfort alongside standard treatments, but it has been shown to help patients live a little longer.

POLST form presented at Northwestern Memorial, a seminar from LMM co-founder Mary F. Mulcahy, M.D.

Image: Mulcahy speaking to a group of physicians at Northwestern Memorial Hospital

“The Illinois POLST form is a step in the right direction,” said Mary F. Mulcahy, a co-founder of Life Matters Media and practicing oncologist at Northwestern University, while lecturing physicians about the form Thursday at Northwestern Memorial Hospital.

In March, the Illinois POLST form was released to the public, an effort headed by the POLST Paradigm and the Chicago End-of-Life Care Coalition. This update to the Illinois DNR advance directive aims to improve the quality of life for patients at end of life.

POLSTs, Physicians Orders for Life Sustaining Treatment, are more detailed than conventional living wills and advance directives. These forms give patients the freedom to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for patients in their last year of life, and they can follow patients across state care settings and direct doctors to provide or withhold lifesaving treatments.

The form should be adjusted over time to fit each patient’s prognosis. “This is not a one-time thing, as patients progress the form can change,” Mulcahy said. “There should be shared decision-making between physicians and patients.” To be valid, the form must be signed by the attending physician.

In the U.S., the average patient visits the hospital more than 30 times and meets nine different physicians during the last six months of life. These patients could benefit from having their medical wishes written down and on hand; the convenience helps cut through the chaos and confusion prevalent in care settings.

POLST was developed in Oregon in the 1990s, and now 14 states have POLST programs. Twenty-eight states are considering the use of such forms.

“Hopefully this form will change the culture and get people talking and preparing for the end of life,” Mulcahy said.

Palliative care expert Andrew Thurston, M.D., agreed. “I think this is great. My hope for the POLST form is that it will clarify patients’ wishes for their end of life care, and that it helps doctors more effectively communicate with their patients,” said Thurston. “We need more open discussion, and with easier language, this form helps.”

More about POLST

Washington POLST form: A new bill aims to close loophole

Illinois POLST form released to public

How POLST forms clarify wishes: Three scenarios

End of life questions from Catholics tackled at National Healthcare Decisions Day symposium

On National Health Care Decisions Day, the Integritas Institute for Ethics hosted a symposium to explore the ethical challenges that arise at the end of life. Roman Catholic physician Ely Wesley, a Vanderbilt University pulmonary and critical care specialist, warned fellow doctors at the University of Illinois-Chicago against the hastening of death, a process that he argued breaks both the laws of God and nature.

Wesley speaking to a room of medical professionals about the "double effect" — Wesley speaking to a room of medical professionals about the “double effect”

The physician told a room of medical professionals, graduate students and caregivers that his Catholic faith shapes his medical practice, and that the two are inextricably intertwined. “People in this room know people who are struggling with their faith and putting it into context,” he said. “I have no incentive to hasten death.”

During his lecture, Wesley made numerous references to scriptures, prayers and Catholic teaching about death and dying. “Physicians have an opportunity that a priest does not have, and our mission does not end when medicine is no longer of help,” Wesley said.

“Human life is sacred from its beginning to its end,” Wesley said, pointing to the teachings of Pope John Paul II. Even though death is not “an awful situation,” since it baptizes the faithful to Christ, he argued that hastening death removes the dignity of the ill and aged.

“How can we do a better job for our older people?” he asked, and decried secularism, ageism and the ongoing political debate about assisted suicide.

“Euthanasia is a grave violation of the law of God,” Wesley said, referencing current battles in many states over “Death with Dignity” legislation. “If you’re not religious, then it violates natural law.”

What Wesley called the “double effect” is preferable, he said, for people of faith. “Double effect” is a terminal patient’s death due to excessive pain medication. This type of death is justifiable, Wesley argued, because it does not aim to end life- only to treat pain.

“It’s scary” that people can purchase ways out of life, he said, noting the rising use of the “exit hood,” a contraption that allows individuals to inhale helium and end their lives. The public support and national popularity of Dr. Kevorkian- a pathologist convicted of second-degree murder for his role in a case of voluntary euthanasia- is frightening also, Wesley argued.

Caring is an honor, Wesley said, referencing a Michelangelo sculpture depicting Christ’s broken body after his crucifixion in a peaceful Mary’s arms. “Look at Mary’s face in the Pieta.”

Learn more from the Life Matters Media Newswire:

“Death denying” culture unfortunate result of medical innovation, says physician on Health Care Decisions Day

Gay man claims discrimination after his arrest at hospital

Community cancer clinics turning thousands of patients away

February 24, 2013

Projects get people talking about end-of-life

As the nation’s baby boomer population begins caring for their aging parents and approaches retirement age, new online resources are aiming to get more people talking about death and dying.

Research shows earlier advance care planning contributes to better end of life care and more comfortable deaths. However, some 80 percent of patients do not plan, according to American Medical News. A new project, Prepare, aims to change this by offering free interactives that help seniors choose medical decision makers and form questions for doctors.

The Web site features large print and simple wording to make it navigable. Simple questions like, “Do you know how to use a computer?” and voice-over directions help those struggling with technology. There are even videos showing actors discussing end of life preferences with family.

“[The] tide in advance care planning has been moving away from forms and toward discussions,” project leader Dr. Rebecca Sudore, a geriatrician at the University of California, San Francisco, told The New York Times’ Paula Span.

Although advance directives remain important, they can be intimidating. Discussions are helpful because “most people make a lot of medical decisions about serious diseases and treatments over the course of their lives,” Sudore said. “They’re not only end of life decisions.”

The Conversation Project

The Conversation Project, launched in August by Boston journalist Ellen Goodman, aims to get families talking to each other about their end of life preferences. Supported by the Institute for Healthcare Improvement, the interactive site provides discussion questions and stories from those who have successfully made their wishes known.

“What we really need is to change the cultural norm from not talking about it to talking about it,” Goodman told USA Today. She said more than 60,000 people have visited the site and thousands have downloaded the free conversation starter kit.

These discussions will only become more common. In 2000, there were more than 35 million Americans 65 and older. By 2030, there will be 72 million.

Learn more from the Life Matters Media Newswire:

Some doctors still believe in psychedelic drugs

Intimacy and end of life: “The Sessions”

Medical Marijuana: DEA continues to classify cannabis alongside heroin and LSD

February 21, 2013

An OP-ED for PBS: Inequalities in the health care system

Life Matters Media co-founder Mary F. Mulcahy, M.D., published her research about the racial and economic inequalities in the U.S. health care system for PBS. She continues to spread the message of advance care planning.

She writes:

“Racial disparities and inequities in American healthcare are evident in daily life, but regrettably they are also prominent in death. In these final days of Black History Month, it is imperative to reflect on the final days of all African-Americans and the choices they have within our health care system. These are the choices they aren’t taking, and the phenomenon serves as a means of further disenfranchisement from the medical community at large.

“The National Center for Health Statistics reports that African-Americans in home health care and nursing homes are half as likely as whites to have an advance directive, such as a living will or a do-not-resuscitate (DNR) order. This disparity leaves African-Americans at risk for unwanted medical procedures, unnecessary pain and family strife.”

Read the rest at PBS

Learn more from the Life Matters Media Newswire:

Death Cafe: A movement discusses end-of-life

Some doctors still believe in psychedelic drugs

February 9, 2013

Costs and benefits of end of life treatment: A TEDMED discussion

Modern medicine allows the terminally ill to survive longer than ever, but debate continues about how much should be spent on aggressive end of life care and if such care is actually best for patients. TEDMED facilitated a live discussion about some possible solutions to these challenges with industry experts this week, as part of its Great Challenges series.

In 2010, Medicare paid $55 billion on doctor and hospital bills during the last two months of patients’ lives- more than the budget for the Department of Homeland Security, according to CBS News. Some 20 to 30 percent of those medical expenses may have had no meaningful impact on the patients’ health, according to the analysis.

The discussion tied those problems to the need for better advance care planning and communication between doctor and patient. End of life concerns take an emotional toll on a patient’s family and friends, especially in the absence of advance care plans, such as a living will or POLST form.

Some families may insist on more aggressive care for the patient because of religious or societal expectations. Some doctors do not adequately communicate a patient’s condition to family, providing loved ones with the false sense that more treatment will work. This failed communication often results in increased spending.

Medical schools continue to improve training in how to listen to patients and mind the severity of illnesses, said Richard Payne, M.D., professor of medicine and divinity at Duke University. “Generally, there is much more emphasis now on teaching doctors to listen empathically to patients and their wishes,” he said.

Although it may be difficult and uncomfortable, it is important to speak with loved ones about death and dying ahead of time, said Bruce Jennings, director of bioethics at the Center for Humans and Nature. “Advance planning and treatment planning are very important aspects of ensuring that the kind of care you receive at the end of life will be beneficial for you, and will respect your wishes and dignity,” Jennings said.

Debate about end of life care will become increasingly common. In 2000, there were more than 35 million Americans 65 and older. By 2030, there will be 72 million.

Learn more from the Life Matters Media Newswire:

The lack of advance care planning persists

Vermont Statehouse votes “Death with Dignity”

Medical Marijuana: DEA continues to classify cannabis alongside heroin and LSD

December 10, 2012

How POLST forms clarify wishes: Three scenarios

The Physician Orders for Life-Sustaining Treatment (POLST) program, designed to improve end of life care in Illinois, is on its way to implementation. Health care professionals met at Rush University Medical Center this week to discuss the form’s development and strategies for raising public awareness.

Julie Goldstein, M.D., a clinical ethicist and palliative care physician at Advocate Illinois Masonic Medical Center, provided the audience with hypothetical scenarios the POLST program form could remedy.

POLST program forms are more detailed than conventional living wills or other advance directives. They allow people to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for people who are likely in their last year of life. They can follow patients across in-state care settings and direct doctors to provide or withhold life-sustaining treatment in emergency situations.

The forms aim to more quickly direct doctors to a person’s wishes and eliminate confusion about what patients would want in the case that they are medically incapacitated and unable to communicate their wishes. The forms provide instructions in the case of a cardiopulmonary arrest (the person has no pulse and is not breathing), the degree of medical intervention they would want in a pre-arrest situation (the person has a pulse and/or is breathing), and whether or not they would want artificial nutrition if their medical illness prevented them from taking in adequate oral nutrition.

How a POLST form could help

A 67-year-old man is sent to the emergency room with chest pain and shortness of breath. He is also confused. The cardiologist says that a cardiac catheterization with angiogram and a stent are needed. The nurse tells the physician that there is a DNR order on his chart. Should the physician send the patient for an angiogram? It’s not clear.

If that patient had a POLST form that indicates DNR in case of full cardiac arrest but an order for full treatment in a pre-arrest emergency, the physician would immediately know what to do. The patient would be sent for the angiogram.

An 85-year-old man is admitted to the emergency room with severe pneumonia. He’s hypoxic, confused and refusing the ventilator. There is a DNR order on the charts. The physician feels that DNR doesn’t apply to this potentially reversible condition but the nurses disagree. He receives full resuscitation.

If that same patient had a POLST form indicating no CPR in the case of arrest and a preference for comfort care, the physician and nurses would have clear instructions. He would not have undergone full resuscitation, but would have been maintained in comfort with noninvasive maneuvers. .

A 59-year-old woman who is being treated for breast cancer is admitted to the emergency room for sepsis. She is transferred to intensive care and receives oxygen and maximum vasopressors. She has a DNR order on the charts. The staff are concerned that they are violating her wishes.

If she had a POLST form indicating no CPR in the case of arrest but limited interventions in addition to comfort measures, the staff may feel more comfortable treating her as they are doing and spend less time deliberating.

Continue reading →

November 29, 2012

Occupational stress: Doctors may suffer when unable to save lives

Physicians who treat the terminally ill may suffer from emotional stress when unable to save patients’ lives. Burnout and compassion fatigue are two serious forms of occupational stress physicians may suffer, according to research by Michael Kearney, M.D.

Kearney, a palliative care physician at Santa Barbara Cottage Hospital in California, describes burnout as “the end stage of stresses between the individual and the work environment.” Compassion fatigue is “secondary post-traumatic stress disorder, or vicarious traumatization — trauma suffered when someone close to you is suffering.”

Health care journalist Jane Brody addresses the stress and anxiety oncologists struggle with in a new article for The New York Times. Brody writes, “A doctor with compassion fatigue may avoid thoughts and feelings associated with a patient’s misery, become irritable and easily angered, and face physical and emotional distress when reminded of work with the dying.” Compassion fatigue may lead to burnout.

Up to 60 percent of practicing physicians report symptoms of burnout.

According to Brody: “Patients and families may not realize it, but doctors who care for people with incurable illness, and especially the terminally ill, often suffer with their patients. Unable to cope with their own feelings of frustration, failure and helplessness, doctors may react with anger, abruptness and avoidance.”

Physician suicide linked to occupational stress

According to Crystal Phend, senior staff writer for MedPage Today, ”Suicide among physicians appears to follow a different profile than in the general population, with a greater role played by job stress and mental health problems.”

Phend cites a study by Katherine J. Gold, M.D., of the University of Michigan in Ann Arbor, who found that problems with work were three times more likely to have contributed to a physician’s suicide than a nonphysician’s. Mental illness was also 34 percent more common before a suicide among physicians.

Up to 60 percent of practicing physicians report symptoms of burnout

“The results of this study paint a picture of the typical physician suicide victim that is substantially different from that of the nonphysician suicide victim in several important ways,” Gold wrote for General Hospital Psychiatry. ”Inadequate treatment and increased problems related to job stress may be potentially modifiable risk factors to reduce suicidal death among physicians.”

Although physicians have more access to health care, they may be reluctant to seek help. ”I think stigma about mental health is a huge part of the story. There is a belief that physicians should be able to avoid depression or just ‘get over it’ by themselves,” Gold wrote.

More than 200 of the 31,636 suicide victims reported in the National Violent Death Reporting System from 2003 to 2008 were physicians.

Meditation may help physicians

A 2008 study published by the Journal of Palliative Medicine, in which researchers studied 18 oncologists, found that physicians who viewed their work with patients as both biomedical and psychosocial found end of life more satisfying than those with a more biomedical perspective.

“Physicians, who viewed their physician role as encompassing both biomedical and psychosocial aspects of care, reported a clear method of communication about end of life care, and an ability to positively influence patient and family coping with and acceptance of the dying process,” the researchers concluded.

“In contrast, participants who described primarily a biomedical role reported a more distant relationship with the patient, a sense of failure at not being able to alter the course of the disease, and an absence of collegial support.”

Kearney recommends “mindfulness meditation,” a Buddhist-influenced practice for physicians suffering from stress. “The doctor is able to recognize he’s being stressed, and it prevents him from invoking the survival defense mechanisms of fight (‘Let’s do another course of chemotherapy’), flight (‘There’s nothing more I can do for you — I’ll go get the chaplain’) and freeze (the doctor goes blank and does nothing).” He claims that even 8-10 minutes a day of “mindfulness meditation” can help.

Learn more from the Life Matters Media Newswire:

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November 14, 2012

Life Matters Media featured in The Huffington Post

Life Matters Media co-founder Mary F. Mulcahy, M.D., has shared her experiences treating the terminally ill for a new feature in The Huffington Post. She continues to spread the message of advance care planning.

“Advance care planning is a dynamic process that evolves over time as a person’s health goes from well, to ill, to ultimately terminal. Less than 10 percent of people will die suddenly; most of us will experience a protracted life-threatening illness. Medical advances have led to few cures of illness, have prolonged the experience of living with chronic illness and have prolonged the process of dying. Add to this the fact that for the next 18 years, baby boomers will be turning 65 at a rate of about 8,000 each day, and it is clear that the role of advance care planning needs to be embraced,” Mulcahy writes.

Learn more from the Life Matters Media Newswire.

Intimacy and end of life: “The Sessions”

Life Matters Media featured in Al Jazeera

September 30, 2012

Mass. Catholics organize against “Death with Dignity”

Roman Catholics remain some of the most vocal opponents to the “Death with Dignity” initiative in Massachusetts, to which voters statewide will answer yes or no Nov. 6. The proposed action would allow physicians to prescribe life-ending drugs to terminally ill patients.

“The largest religious force in Massachusetts, the Roman Catholic Church, has come out squarely against the referendum, as have other prominent faith voices,” The Boston Globe’s Lisa Wangness writes. “The church teaches that human life is sacred from conception to natural death, and that suicide in any form is a grave sin.”

The Globe’s Chelsea Conaboy also reports that, “Catholic archdioceses from across the country contributed tens of thousands of dollars to the Committee Against Physician Assisted Suicide, which raised $900,550 from late April to September.”

According to New England’s NBC affiliate NECN, Catholics are organizing church by church against “Death with Dignity.” For example, St. Jerome Parish in Weymouth, Mass. is holding workshops encouraging parishioners to vote “no” on the initiative, also known as Question 2.

The initiative referred to as “Prescribing Medication to End Life” has a number of restrictions. “Patients would have to be determined capable of making and communicating their health care decisions, have at most six months to live and voluntarily express a wish to die on two occasions, 15 days apart,” reports the Concord Journal. A patient and his or her physician would also be required to discuss the option of palliative care.

In a blog post for Boston, Dr. Marcia Angell, a supporter of the proposal, writes: “No physician is required to participate in assisted dying; he or she may refuse for any reason whatsoever. This is a choice, not a requirement, for both patients and physicians.” Dr. Angell is the former editor of the New England Journal of Medicine.

The Massachusetts Medical Society and the Massachusetts Family Institute also oppose the act. The former president of the Society, Dr. Barbara Rockett, writes in a foil post: “We as physicians must avoid the so-called slippery slope of attempting to save money by doing less for our patients rather than rendering the proper care to them. To substitute physician-assisted suicide for care represents an abandonment of the patient by the physician.”

States currently allowing assisted suicide include: Oregon, Montana and Washington.

A 2012 study by the Yale Journal of Biology and Medicine analyzed Oregon’s 1994 adoption of “Death with Dignity” and its Catholic response. According to the study, “The Church used its pulpits to urge Catholics to vote against Measure 16 (the Act) and make a political contribution to the Coalition for Compassionate Care,” similar to the current Massachusetts response.

However, one of the biggest differences between Oregon and Massachusetts is the Catholic population. “[S]ince Oregon had only a small percentage of Catholics in the state, most Oregon voters saw the Catholic Church’s involvement against Measure 16 as an attempt by organized religion to impose its views on the public,” Taylor E. Purvis writes.

According to Pew Research, 43 percent of Massachusetts residents claim the Catholic tradition as their religious preference. Massachusetts has a larger percentage of Catholics than any other state.

The high percentage of Catholics is not, however, translating into statewide opposition to Question 2. A new Suffolk University poll of likely voters shows 64 percent would vote “yes” and only 27 percent would vote “no” on the initiative.

Read the full petition here.

Learn more from the Life Matters Media Newswire.

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End of life counseling or ‘death panels’

Should faith healing be considered legitimate treatment?

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