Sunday, February 28, 2010

Palliative Care - 1996 and 2010

More than 13 years ago, Philadephia Inquirer reporter Michael Vitez wrote a series about end-of-life care which won a Pulitzer Prize - see here for the first installment of that five-part series.

Some excerpts from that piece:

"Medicine has gotten so good at keeping people alive that Americans increasingly must decide how and when they will die. They must choose if death will come in a hospital room with beeping machines and blinking monitors or if it will come at home, with hospice workers blunting the fear and pain that so often accompany the final hours."
"The intensive-care unit offers a hope for recovery, but the price can be a miserable death. Deciding when to surrender can be a torture all its own."
"Advocates for change believe doctors are too optimistic, too sparing in what they tell patients. They say that families would be more willing to accept death earlier if doctors were more honest, more realistic. Reformers want to make sure that patients get the care they need, but not unnecessary or unwanted treatment. The key to humane and cost-effective intensive care is to treat those who will benefit, but not squander precious resources and impose futile treatments on those who will not. But often it is impossible to know who will live and who won't."

In today's Philadelphia Inquirer appears an article by Michael Vitez (read here), as part one of an occasional series on the dilemmas facing today's hospitals. The subject is how hospitals are addressing end-of-care issues, and in his article Mr. Vitez follows the work of the palliative care team, led by palliative medicine physician Dr. Diane Dietzen, at Abington Memorial Hospital, a large, suburban Philadelphia hospital. An insightful article, one that lays out in very personal stories the challenges faced by families and providers alike. In Mr. Vitez' words: "My goal is to spend a year at Abington, writing stories that show how one hospital deals with the biggest issues in health care today and also the changes that are coming fast and furious - regardless of what Congress and the President do - to hospitals and health care.
This first story looks at how the palliative care movement is medicine's response to the dismal way people have died. I try to show, up close, how the team works, the agony that families feel, the immense costs involved. "

Has much changed around end-of-life care in those 13 years? Surely, a patient in an ICU with a poor prognosis is more likely today than 1996 to be consulted by a palliative medicine physician such as Dr. Dietzen. But how much more likely, and if a consult is requested, is the timing appropriate? Just as surely, large variations in late-life care continue to persist among hospitals and communities, still raising questions about the appropriate role for acute hospital care in the management of patients with advanced illnesses.

As one of the doctors in the 1997 article stated ," America wants to offer the most advanced technology and treatments to everyone, yet keep health-care costs down."
How to balance those desires, the doctor added, "is a discussion nobody wants to have." Thirteen years later, when one considers the discussions taking place in the name of health reform, one must wonder how far have we advanced.

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