BY RAJ BUDDHAVARAPU
I stood by the bed of an 85-year-old patient clearly in pain. He was short of breath, caused by the acute pneumonia that had led to his hospitalization. He suffered from severe pain in the chest and legs. His grown sons were agitated ”” yet their father”™s discomfort was not their sole concern. The patient was refusing all aggressive treatment, and his sons disagreed. But the patient had practiced medicine for more than 50 years; he knew further treatment would not cure him and would cause him to suffer more. Now his sons needed to try to understand what their father”™s wishes really were.
As director of geriatrics and palliative care at White Plains Hospital, I encounter similar situations several times a day. Patients feel powerless, and families face a difficult choice: doing everything possible to save their loved one”™s life ”” even if there is no certainty of a cure ”” or following their loved one”™s wishes to be left in peace. My role is to talk to patients and families about what we as medical experts can do, and what we cannot do. If we cannot cure the disease, we can provide comfort for the patient during a very difficult time.
In the case of the 85-year-old former physician, I spoke to him about what he valued most at this time in his life. He understood that the pneumonia, compromised heart function and fluid in the lungs were life-limiting, and that the pneumonia would eventually claim his life. He did not want to go home; he wanted the hospital to provide palliative care that would block his pain and allow him to ease into death. He feared that if he went home, his wishes may not be carried out in the face of resistance from family members again. He was assured, after speaking to me, that his wishes would be carried out in the hospital.
Meanwhile, the sons struggled to understand their father”™s choice, but they were comforted by talking to a medical professional who could paint a picture of exactly what their father faced. They began to see that the treatment would be more burdensome than the disease. They agreed with their father”™s decision, and they and their father were grateful. A few days later, the father died in peace.
Let”™s start talking
The end of life is a difficult time for patients, families and physicians. Physicians are trained to fight disease to the end and are uncomfortable initiating a discussion of alternatives with patients and families. Families are reluctant to broach the topic themselves, thinking it is best to defer decisions to medical experts. But as uncomfortable as it is, physicians need to initiate these conversations. I believe it is our responsibility as medical professionals to look beyond the physical to take into consideration the values, culture, spiritual pain and emotional turmoil that beset patients and families.
White Plains Hospital has made it a priority to engage patients in end-of-life discussions. We educate our staff ”” physicians, hospitalists, specialists, nurses and social workers ”” on the importance of initiating these discussions. We plan in-depth lectures and convene meetings with separate specialty groups. They are shown how to speak to patients and their families about how they are coping with the illness.
In addition, we have developed a screening tool to help clinicians identify patients in need of the discussion. We encourage nurses as well as physicians to use it, as nurses spend more time at the bedside. Patients are made aware that they can feel free to seek a consultation or change in treatment plan at any time.
Our culture has changed
Now, more of us are initiating these important discussions. We listen as people unburden themselves, describing the spiritual, mental and emotional pain the disease causes. We carefully describe possible treatment plans and alternatives, highlighting the risks and benefits, and discussing it all until every question is answered. We make sure the patient and family have the information they need to give informed consent for proposed interventions.
Part of our process is to invite physicians to forums where they can share their experiences and grow more comfortable having these conversations with patients and families. What we are finding is that physicians find the work fulfilling and gratifying. Families are grateful to have a medical professional guide them through the process. It relieves them of doubt, eliminates the guessing and brings closure, whether aggressive treatment continues or not.
By helping our clinical professionals gain the necessary skills and competencies to engage in sensitive conversations at the end of life, we are fulfilling our commitment to center our care on our patients while respecting the values and spiritual needs of both them and their families at a crucial time. It is a practice I hope will become commonplace throughout our health care system.
Dr. Raj Buddhavarapu is the director of geriatrics and palliative care at White Plains Hospital. For more information, call 914-681-1072.
Article by Raj is worthy of every consideration