Generally it is acceptable to begin palliative care in people who have a terminal disease who will no longer benefit from “curative” medical interventions. The term “curative” as we all know is actually rather deceptive. After all, there are only a handful of diseases that can actually be “cured” and they most often relate to childhood cancers. The rest of medicine is designed to alter the physiologic processes of the body in order to help the organism (aka patient) compensate.
Originally, medicine was designed to help people maintain productivity. This was during a time when social safety nets basically did not exist. If you couldn’t grow or hunt your food, or do something in order to trade for it, you would simply die. Being productive was synonymous with life.
However, medical knowledge also was useful for palliating terminal patients; some on the battlefield and others in the civilian world. Recognizing the inevitability of the end, comfort care of the dying was simply the humane thing to do.
However, over the centuries, as people, medicine, and society evolved, so too has diseases that affect humans. The purpose of medicine is no longer to keep people productive, but to keep people living. As many of us witness daily, this is simply an impossible task. We are trained and encouraged to help people lead healthier lifestyles. Eat right, quit smoking, exercise, and all manner of non-medical intervention.
But how many patients actually choose to do this? An abysmally small percent… So facing death, which may not seem real until the active dying phase because of the actual amounts of time involved in chronic disease and the relatively painless symptoms, it seems patients have no interest in actually curing or putting off disease, but simply want to be defiant to the end.
This attitude, philosophy, mentality, whatever you want to call it is enshrined in American culture. Let’s face it, what America does for better or worse, the world usually copies.
“I have not yet begun to fight” was famously stated by John Paul Jones, an early American naval officer, in response to a British request to surrender after the initial stages of the engagement which left his American ship sinking. In the end, the American ship did sink, but after taking the British ship a prize, the Americans declared it a great victory. A great fight for sure (in the man vs. man sense) but arguably, pretty much a draw, after all, everyone lost a ship.
Has medicine become the same? Patients do not want to actively take care of their health, but instead wish to continue the lifestyle they have chosen as long as possible. In order to do this, they require pills, and surgery, and all manner of treatments forcing science to push the envelope further every day.
In essence, they know their ship is sinking, and they call the doctor and begin to fight; in the end, not seeking to win, but merely to stay afloat a bit longer.
Now it is obvious that circumstance often dictates this choice. After all, when your 10,000 calorie McDonald’s meal is only $5, but your 350 calorie Mediterranean salad is $10 and you have a limited amount of money, McDonald’s is the clear choice. (Starving isn’t healthy either.) Some can be blamed on education, tradition, culture, history, and a myriad of other factors.
But I am not here to explore healthy living or what can be done to help people be healthy. Other people get paid to do that. I am here to talk about a decision point.
I have only a handful of friends who are not healthcare providers. Even among friends that are healthcare providers of some type, only a small percentage are not some form of Critical (Acute) Care provider. (Emergency, Intensive Care, Surgery) We are simply not in the business of health promotion.
So at what point is further medical care futile? During the active dying phase after a resuscitation event or the end stage of a terminal cancer is a no-brainer. But what about the 50 year old morbidly obese patient, whose idea of productivity is making it to the fridge and back between TV commercials? What about the diabetic sitting in the ED bed eating cookies while waiting for lab results or the surgery patient for yet another amputation?
Most Critical Care providers I know do not want to be resuscitated, or only in under very select circumstances, usually revolving around a return to a comparable level of previous function. People not a part of this acute care lifestyle generally talk about a quick death being preferable to a prolonged one. But yet when they are told the foot has to come off, or the leg, they cry and ultimately acquiesce, all pretense of fighting spirit gone. Right up until after the surgery when the mental shock subsides, they retake up defiance with the mantra of “it’s over and I have nothing more to lose.”
So after a few years in the medical system, well before they get to these extreme points, why don’t we just say “you might go out with DKA, but you’ll be eating your burger right up until the end.” Maybe a catchy slogan, like “have some fries for your M-Is?”
Now I am not suggesting not treating people, quite the contrary. But I am asking when the determination of switching from “curative medicine” to palliation should be determined.
It extends beyond chronic diseases to other inflictions. For example, a popular topic among emergency providers is not providing opioids to addicts. What “curative” treatment do we offer? It certainly isn’t effective substance abuse treatment. At what point do we decide in the battle of life, you lost, so let’s practice the time honored medical tradition of making your death as painless as possible?
I have given 2 examples, but I could go on and on. We cannot use medicine to give people the life we want them to have. We can only help them along in the life they do have. Otherwise I will please have a prescription for wealthy, sexy, and completely carefree. Furthermore, I don’t want to be the person in the nursing home all alone because I am so much a burden on my family they cannot possibly take care of me. I suspect many of you reading want the same. Why are we so quick to use medicine that will give that very drawn out end to others instead of telling them to live it up and helping them?
Wouldn’t helping them have the life they choose until the end, even if it was years less, medicine that would make people feel better? Hacking them to death a piece at a time or polypharm treatment until they are so sick they cannot function or even want to be around people because of the side effects doesn’t seem like “reasonable medical treatment” to me anymore. In fact, I am not even sure it was ever “reasonable,” but it sure made me feel good to do it to somebody else.