Shirah Vollmer MD

The Musings of Dr. Vollmer

Palliative Care

Posted by Dr. Vollmer on November 29, 2010

    Taking control over one’s death; why don’t we do that? Lee, fifty-five year old African-American male, heavy smoker for forty years, heavy drinker for twenty years, but now sober for ten years, is dying from metastatic lung cancer. He is in agonizing pain; he has good insurance. The pain doctors, or so they call themselves, are hesitant to give him opiates because he has a substance abuse history. “No way,” I say to the family. “That can’t be true,” I repeat in total disbelief. Yet, it is true. “Well, then get him a new pain doctor” I say, with a demanding tone, realizing that for inpatient pain management, there may not be a lot of choices. Eventually, Lee says “put me down” with such clarity that he realizes that living must be worse than dying, at least as far as he is concerned. Veterinarians heed the call of the animal, when the dog or cat or bird is nearing the end of his days. Physicians on the other hand, tend to be insensitive in this domain. Although palliative care is a growing field, most dying patients do not receive services which help a faster, more peaceful exit. Mental health providers, by and large, have also remained silent. Why don’t psychiatrists, psychologists, and social workers speak out, about how for the sake of the person, for the sake of humanity, let’s help this patient die?  Our silence is deafening. It is time to change health care policy for end of life care. Shortening life, in the face of a terminal illness with chronic pain, is both humane and cost-effective. We have to stop pretending that both issues are not important.

4 Responses to “Palliative Care”

  1. John said

    Thanks for your timely entry on so-called palliative care. I noticed you did not mention hospice, however. As a former hospice social worker, I can say without hesitation that this patient’s family should demand referral to hospice, for three reasons. First, hospice physicians often confer with family doctors and oncologists, which helps to eliminate misunderstandings about priorities. Second, no hospice medical director would ever refrain from using opiates because of a patient’s substance abuse history; and third, hospice staff and nurses know how to manage pain, a subject about which most primary care doctors and (especially) oncologists are ignorant. Finally, I applaud your blog entry about this subject,as it is clearly necessary to educate many physicians about end-of-life care.

    • Yes, I should have mentioned hospice-another post perhaps. The patient’s family did in fact demand hospice, but the delay (about 24 hours) was excrutiating. I agree that hospice folks are skilled at pain management and I also agree that most non-hospice medical professionals are not trained in end-of-life pain management. As you imply, if we knew we could die peacefully, maybe it would not be so scary. Fear generates a lot of unnecessary, painful and costly procedures. Thanks.

  2. Shelly said

    Perhaps the palliative-care doctors didn’t believe that Lee was dying and that it was all a ploy for opiates? I agree, if Lee was in hospice, then it would have been clear that he wasn’t trying to get a fix. Could you talk to the physicians to help try to smooth things out a little, remind them of their oath to try to help not harm?

    • Lee had an aggressive tumor. The word “believe” is interesting, because although doctors can be terribly wrong, usually the pathology is indicative of the severity. Either way, pain control should have been of prime importance. Yes, I can serve as a mediator between various physicians involved in his care, but the time it takes for them to call me back, meant that the waiting meant that the patient and family were suffering horribly. Pain, as we all know, is a time sensitive manner, and doctors are not always responsive in a timely manner. The system of “dying” in the United States is broken. It needs to be fixed.

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