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 "Letting Go: What should medicine do when..." 
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Joined: Fri Aug 11, 2006 1:46 pm
Posts: 4811
Location: SF Bay Area (Northern CA)
Post "Letting Go: What should medicine do when..."
There's a thought-provoking article in the August 2010 issue of "The New Yorker" magazine on modern medicine being "good at staving off death with aggressive interventions -- and bad at knowing when to focus, instead, on improving the days that terminal patients have left."

Here are some excerpts:

* People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this system’s expense. It is how we can build a health-care system that will actually help dying patients achieve what’s most important to them at the end of their lives.

* In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.

* The difference between standard medical care and hospice is not the difference between treating and doing nothing... The difference was in your priorities. In ordinary medicine, the goal is to extend life. We’ll sacrifice the quality of your existence now—by performing surgery, providing chemotherapy, putting you in intensive care—for the chance of gaining time later. Hospice deploys nurses, doctors, and social workers to help people with a fatal illness have the fullest possible lives right now. That means focussing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as possible, or getting out with family once in a while. Hospice and palliative-care specialists aren’t much concerned about whether that makes people’s lives longer or shorter.

* It’s worth pausing to consider what had just happened. Step by step, Sara ended up on a fourth round of chemotherapy, one with a minuscule likelihood of altering the course of her disease and a great likelihood of causing debilitating side effects. An opportunity to prepare for the inevitable was forgone. And it all happened because of an assuredly normal circumstance: a patient and family unready to confront the reality of her disease.

"It has become, in my view, a bit too trendy to regard the acceptance of death as something tantamount to intrinsic dignity,” [Stephen Jay Gould] wrote in his 1985 essay. “Of course I agree with the preacher of Ecclesiastes that there is a time to love and a time to die—and when my skein runs out I hope to face the end calmly and in my own way. For most situations, however, I prefer the more martial view that death is the ultimate enemy—and I find nothing reproachable in those who rage mightily against the dying of the light.”

The fact that we may be shortening or worsening the time we have left hardly seems to register. We imagine that we can wait until the doctors tell us that there is nothing more they can do. But rarely is there nothing more that doctors can do.

Two-thirds of the terminal-cancer patients in the Coping with Cancer study reported having had no discussion with their doctors about their goals for end-of-life care, despite being, on average, just four months from death.

“A family meeting is a procedure, and it requires no less skill than performing an operation," said Dr. Susan Block.

According to Block, about two-thirds of patients are willing to undergo therapies they don’t want if that is what their loved ones want.

And here's a link to the article: ... ntPage=all

Wed Jul 28, 2010 8:41 pm

Joined: Wed Jun 09, 2010 4:53 pm
Posts: 42
Location: Davis, CA
Post Re: "Letting Go: What should medicine do when..."

Thanks so much for posting this article. I read it in the magazine but thanks to your posting I can send it out to others. I was a little disappointed that they focused so much on cases involving young people rather than elderly people. It seemed that the cases were extreme and involved much more complex decision making than what we go through with out elderly parents and spouses (although I know many who post have younger loved ones). I thank God that my parents had thought through all of those end of life decisions (with much prodding on my part - I was the only sibling willing to talk about these things). I have a friend whose mother-in-law was dying of pancreatic cancer and remained in denial and wanted every extreme measure possible. It was a very painful experience for the family.

Again, thanks.


Sat Aug 07, 2010 12:24 pm

Joined: Fri Aug 11, 2006 1:46 pm
Posts: 4811
Location: SF Bay Area (Northern CA)
Post Re: "Letting Go: What should medicine do when..."
There's a related article in today's New York Times about a randomized trial of palliative care vs. no palliative care for cancer patients. "Those getting palliative care from the start, the authors said, reported less depression and happier lives as measured on scales for pain, nausea, mobility, worry and other problems."

"Palliative care typically begins with a long conversation about what the patient with a terminal diagnosis wants out of his remaining life. It includes the options any oncologist addresses: surgery, chemotherapy and radiation and their side effects. But it also includes how much suffering a patient wishes to bear, effects on the family, and legal, insurance and religious issues. Teams focus on controlling pain, nausea, swelling, shortness of breath and other side effects; they also address patients’ worries and make sure they have help with making meals, dressing and bathing when not hospitalized."

"Hospice care is intensive palliative care including home nursing, but insurers and Medicare usually cover it only if the patient abandons medical treatment and two doctors certify that death is less than six months away."

Wed Aug 18, 2010 11:55 pm
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