Monday, June 29, 2009

Magical Thinking

Zusne and Jones (1989: 13) define magical thinking as the belief that that one's thought, words, or actions can achieve specific physical effects in a manner not governed by the principles of ordinary transmission of energy or information.

When I went to medical school, we were taught that magical thinking was either a harmless superstition like crossing one's fingers to bring them luck, or a dangerous psychotic delusion, like stepping off a ledge and expecting that you are going to fly.

Since school, I have observed (and frankly participated in) varying degrees of magical thinking. Some lines of thought are fun and some are scary but all have at their core the fervent hope that things will be different than what they are for real.

Since my "evolution" as a physician I have been able to observe that the most ardent practitioners of magical thinking are those of us in the medical profession. It is common practice, for instance, when performing minor procedures at the bedside to disinfect an area of the skin three times prior to performing the procedure. There is no evidence to prove this, but it is commonly done... so much so that the little packets of iodine swabs used for skin disinfection have three little pre-saturated swabs.

Much of this has come down to us from the middle ages mixed with the very real concerns for public health and the provable infection control practices of modern medicine... but still curious.

Unfortunately there are two common threads of magical thinking out there that are perpetuated by the health care community.

The first one is that medicine and medicines can cure anything from cuts and bruises to severe depression. Like any good magical thought, it has it's basis the provable facts of cure from many diseases, however medicine cannot cure many of the ills associated with life itself, such as aging, self abuse such as smoking and obesity. These require the more tedious and "obnoxious" change in lifestyle.

The second (and infinitely more cruel) form of magical thinking is perpetuated by the fears and hopes of medical practitioners themselves. When a person is found to have a terminal illness of any kind (cancer, heart disease, lung disease, etc...) rarely is this information related to the patient. The severity and need for frank and honest discussion of the very real prognosis is held back in the "magical thought" of not wanting to take away hope. Often the thoughts of the practitioner and the thoughts of the family and patient become so intertwined that they begin to exist in each other's fantasy of cure, instead of the reality of treatment and hope for a good life for as long as it lasts.

I am a deeply religious man and I believe strongly in prayer and the power of hope. I have seen in my life what I perceive as being true miracles. However I have seen these miracles happen in the face of a patient that realizes that these are indeed miracles, that these cures and recoveries are the products of a higher power and not the result of crossing our fingers and rubbing our rabbit's foot for luck.

Thursday, June 25, 2009

"Pal Care" and Shoeboxes

Recently, my team and I were sitting and talking with a patient who was hospitalized due to severe pain from multiple myeloma. On her admission, this lovely vivacious woman was reduced to a cringing shell, praying for death.
Fortunately, we were able to positively affect her symptoms and she became much more talkative and showed us a spunky, flirtacious woman who has more life than three normal people combined.
She has labelled our team "Pal care" and I asked her if it was really that hard to say the word palliative? She laughed and said... "No silly, you guys are my pals, so you guys are Pal care".
What a great idea and one which caught us all aback, yes indeed we try to be the patient's Pal.
This lovely woman also explained to us that we now have a Pal Care shoebox.
When asked to explain, she said that everyone has a shoebox, the oncologists live in the cancer shoebox, her fears live in the stinky thoughts shoebox, and now we are in the Pal care shoebox. I cannot think of a better description of "compartmentalization".
Today, as she was preparing to leave tomorrow morning, she asked me to stay behind and speak privately to her after the team left the room.
She spoke to me of her fears... fears of death... fears of a life of pain... and fears of saying goodbye to the hospital family she has grown to love, even without knowing their names.
As I left, she touched my hand and said, "thank you for helping me deal with the stinky thoughts shoebox".

Sunday, June 14, 2009


As of this writing, I am on the eve of removing the ventilator support for one of my favorite patients in the world. I have known her for over 15 years and she is one of the few remaining patients that I continue to see from my pre-palliative care internal medicine practice. She has severe Adult Respiratory Distress Syndrome due to sepsis and pneumonia and she is near death already on multiple pressors and full support.
In her terminal episode, she has taught me many things.
Once again I was reminded that I cannot fix everything, no matter how hard I tried.
I found myself tearful as I ordered her intubated... a chill running through me and an unspoken cry of "Oh my God this can't be happening" in my gut.
I found that I had to let go... I had to let another physician - an intensivist - take over her primary care (difficult because I am a trained intensivist), because I am definitely "too close".
And I found myself today sitting with her son in her isolation room in the ICU... two grown men talking about the end of a lovely woman's life, while we were wearing green isolation gowns, yellow masks, latex free gloves, and "poofy" blue bonnets.
In one instant tears became laughter as I visualized us both in those ridiculous outfits and I shared it with her son.
He laughed... and said that in the end... his Mom would have been hysterical laughing at us both.

Wednesday, June 10, 2009

Dealing with the loss... when death is no where to be seen.

The loss of a loved one is never easy. 
It never seems right nor fair.  
However when death follows a long arduous trial by a disease such as cancer, emphysema, heart disease, or kidney disease... it seems almost a welcome end to the suffering, an end to the pain.
Similarly, when death follows from a massive trauma in which our loved one is maimed and disfigured... death brings relief and the knowledge that no indignity will further disfigure the beauty of our loved one.
But what happens when death is rapid, and yet nowhere to be seen?
What happens when our mother, father, brother, sister, cousin, uncle or other relative lays in the bed on a ventilator... pristine and beautiful, body untouched by the ravages of disease nor the disfigurement of injury?
Recently I cared for two patients, a young man and a young woman who both suffered hypoxic encephalopathy... no trauma marred their bodies... no disease ravaged their lives... the circumstances where at once rapid and fatal, but through our technology, we were able to restore cardiac function.
It fell to me to explain to the family of each of these patients that your son... that your mother... who looks so beautiful and pristine save for the tube coming out of her mouth, is dead.
No shadow over her bed. 
No scars to make his death heroic.
No epic story to make us rejoice at the release of death.
Just two perfect bodies, devoid of the "person" who used to inhabit them, laying in the bed.
And two beautiful families dealing with death... when death is nowhere to be seen.

Thursday, May 28, 2009

Who Builds These Things Anyway?

One of the greatest truisms that I have encountered in my medical career (palliative or not), is the fact that most hospitals are designed by people who have never been a patient, much less seen one. Neither did they ask a doctor or a nurse. 
A particular grievance that I have is the design of bathrooms. Most hospital bathrooms that I have encountered are made small (think the smallest airline bathroom you've ever seen) and would never fit anyone with a walker, cane, wheelchair, much less a person of "size".
If there is a bathroom sink... it is the size of a small finger bowl and has - of all things - foot pedals to work it. Please remember your last hospital visit and what you wore on your feet.
Secondly, from a more palliative standpoint, there are no areas in which talking with families in privacy is possible. This past week, I held family meetings about serious end of life issues in a hallway, staff lounge, and at the elevator lobby. There needs to be a movement to provide private spaces for the talk that is necessary to discuss all aspects of a person's medical care.

Monday, May 25, 2009

We're not all on the same page...

Here’s the scenario: mom is clearly at the end of her life. She has been brought into the emergency room for care. She has no advance directives and is unable to speak for herself. There exist two choices for mom’s care – the Intensive Care Unit for aggressive management, possibly with ventilator support, or palliative care with the focus on comfort care.

There are numerous children, family and friends involved with mom and they are getting input from every source. Someone knows someone who has the same disease process as mom and they had a round of chemo and are cured of stage IV metastatic disease. Someone knows someone who is a doctor or nurse and they have a host of recommendations to follow not having seen the patient.

The family is confused and at odds over what to do.  No one agrees on what mom would want or what they want for mom. Dad is looking at his bride of over 50 years and does not want to entertain the idea of losing her but feels she’s had a good life and wouldn’t want aggressive treatment. The son thinks that in not doing anything aggressive is akin to murdering mom. The daughter does not want her to be in pain. Another daughter is hoping for a cure. No one speaks to the daughter who lives out of state but is the most vocal in what she wants done for mom. And then there are doctors who will offer a chance at some curative therapy in the hope and belief that mom may be of that very small percentage of people who at this stage in the disease will have some degree of remission. There are also doctor’s who will not tell the family that their mother is at the end of her life maybe because they can’t let go of trying to be curative or maybe they are just afraid of having the discussion about death and dying with the family. The family is overwhelmed, confused, angry, sad, grieving. They are fighting with nursing staff and each other.

Here’s where we come in, our first step is to recognize we can’t cure the patient’s disease or the dysfunction of the family. We set up a family meeting to help provide the family with all the information they need to make a decision regarding the goals of care for mom and to help them focus on quality of life. Most times we are able to help the family get on the same page. And sometimes we are not able to do so. We have yet to come across the perfect family. Every family we come across has some degree of dysfunction.

Sometimes the family has members who are in such denial or have such a strong fear of losing their loved one they will continue futile care and continue artificial means to keep their loved one alive – even at the cost of quality of life. Often, the unreasonable family members, the angry family members remain as they have always been prior to mom’s illness – unreasonable and angry and they frequently stand in the way of family decisions regarding care.

The lesson here is to make sure that you clearly speak to your family about what you want should you be unable to speak for yourself. Appoint a health care proxy who you know will follow your wishes and will focus the care you receive on the quality and comfort level you would want should you not be able to speak for yourself. 
Donna Willenbrock, BS, MS, ANP

Friday, May 22, 2009

On the need to look down...

A transformative experience is one in which your perception of reality is changed forever. One of mine was during my training (Pulmonary medicine and Critical care) for critical care. It was a long holiday weekend and I had been on call in the hospital for 5 full days... these were the days before hour limits to Doctor's work... and we were doing rounds in the ICU my last morning on call.
As I stood with my rested and well groomed colleagues, I noted that while everyone was looking up at the monitors above each patient's head, and at the charts at the bedside, and closely scrutinizing the mechanical ventilator at the side of the bed... no one was looking at the patient in the bed. The person who was sick was lost amidst the sea of wires, tubes, academic quotations, calculations and the need to beat death.
I slowly walked to the bed and placed my hand on one of my patient's chest... feeling the air go in and out of him. I never saw the world the same way again.
The simple act of looking down... looking away from technology and towards the humanity, towards the spirit itself will change you. In time... it will change the system.
Look up, see the technology that allows better life, but then look down and see the person the technology was meant to serve.

Quotes from the Front Lines of Palliative Care I

Anyone who has done the "work"of palliative care can come up with quotes that are memorable, either that a team member says or that a patient says. Some funny, some poignant... these little mental "truth bites" are the sound track of our lives as the facilitators of dignity for our patients. Here now a list to get you started:
  1. "Hi we're from Palliative Care... and we're sorry" This is unfortunately not as funny as it would seem. Often our team is called in when situations are out of control, either from the dire emotional stress of the illness or the perceptions of neglect from a stressed family. Nine times out of ten we can remedy this situation, but there are those times we go up in flames.
  2. "I just want to know that I'm doing this right... "  A quote from a woman dying of ovarian cancer. We are all very proud of being in control. I believe that the biggest emotional hurdle we face in our work is the fact that the person faces a betrayal of their sense of identity, but from their own bodies. This woman was a type A control person, who always overachieved, always won, and always did everything right. In the end, her greatest concern was that she was "doing her dying" right.
  3. "No one gets off this planet alive" Reality check for those times when families and/or physicians get the idea that our tragically ill relative will pull through the 50 or so illnesses that they are battling.
  4. "No CPR Doc, when this tire goes flat... throw it in the dump!" New York truck driver with end stage colon cancer reaction on being approached for Advanced Directives. He obviously adamantly refused the offer of death-extending CPR.
  5. "You think better sitting on your ass than laying on your back" Same truck driver when asked whether he wanted to have the family meeting while sitting in a chair or laying in a bed. This is truly a multi-situation piece of wisdom when you stop to think about it.

Sunday, May 17, 2009

It's OK to talk about the scary stuff

When I go to speak to people at the bedside, or when I see people in consultation in the office I often ask, "how do you feel?" Most of the time I get the usual litany of physical complaints, but sometimes I ask that question and I get answers that go beyond the physical.
"I'm tired" is one of those answers that I often hear... what is interesting and disturbing about this is that it is obvious that they are talking about more than physical fatigue. "I'm tired" has become code for "I am done and I want to talk and no one wants to hear it".
Conversations about how it feels to be very sick... and even thoughts about dying can be disturbing to hear, especially if it is a loved one and you really don't want to hear it.
I suggest that if you care for someone who is chronically ill or dying, listen to what they have to say. Let them complain, let then cry, let them tell you they can't go on. These are not evil thoughts, these are not suicidal thoughts, these are the thoughts that are silent... unspoken inside the mind of your loved one. These thoughts... unspoken... will fester inside and cause real damage, real separation and real sadness.

Thursday, May 14, 2009

Making sense of medications near the end of life.

As in all things in life, the end of it should be tinged with a little common sense.
One of the silliest things I have do as a Palliative physician is to sift through the lists of medications that my patients are on and make the useless ones go away.
For instance, what sense does it make if you are suffering from cancer to take cholesterol lowering medications? Not only is it unnecessary, but they can interfere with chemotherapy and can certainly interfere with the enjoyment of life.
My advice to patients and their families who are in this situation, is to review the medication list with their physician and try to exclude anything that will not benefit them in the "here and now" and for comfort sake.
What good is the statistical chance of decreased stroke 25 years from now when the medications to do that make you miserable or worse, shorten your lifespan interfering with your chemo?
With medications such as the lipid lowering agents, daily aspirin therapy, and the like, once you achieve clinical remission or cure, then you can resume all those medications for long term preventative care.

Wednesday, May 13, 2009

What is Palliative Care?

What is Palliative Care?


Palliative care (pronounced pal-lee-uh-tiv) is the medical specialty focused on relief of the pain, stress and other debilitating symptoms of serious illness.

Palliative care is not dependent on prognosis and can be delivered at the same time as treatment that is meant to cure you. The goal is to relieve suffering and provide the best possible quality of life for patients and families.

Ensures quality of life

Palliative care is not a one-size-fits-all approach. Patients have a range of diseases and respond differently to treatment options. A key benefit of palliative care is that it customizes treatment to meet the individual needs of each patient.

Palliative care relieves symptoms such as pain, shortness of breath, fatigue, constipation, nausea, loss of appetite and difficulty sleeping. It helps patients gain the strength to carry on with daily life. It improves their ability to tolerate medical treatments. And it helps them better understand their choices for care. Overall, palliative care offers patients the best possible quality of life during their illness.

Palliative care benefits both patients and their families. Along with symptom management, communication and support for the family are the main goals. The team helps patients and families make medical decisions and choose treatments that are in line with their goals.

Different from hospice

Palliative care is NOT the same as hospice care. Palliative care may be provided at any time during a person`s illness, even from the time of diagnosis. And, it may be given at the same time as curative treatment.

Hospice care always provides palliative care. However, it is focused on terminally ill patients-people who no longer seek treatments to cure them and who are expected to live for about six months or less.

Provided by a team

Usually a team of experts, including palliative care doctors, nurses and social workers, provides this type of care. Chaplains, massage therapists, pharmacists, nutritionists and others might also be part of the team. Typically, you get non-hospice palliative care in the hospital through a palliative care program. Working in partnership with your primary doctor, the palliative care team provides:

  • Expert treatment of pain and other symptoms
  • Close, clear communication
  • Help navigating the healthcare system
  • Guidance with difficult and complex treatment choices
  • Detailed practical information and assistance
  • Emotional and spiritual support for you and your family