Wednesday, July 14, 2010

Block 1: Palliative Care

I recently started my 3rd and final year of Internal Medicine Residency (woo-hoo, almost done!!). I realize, however, that most of my non-medical friends and family really don't understand what residency entails. How could they? This whole medical training thing is the most confusing, needlessly long, expensive process ever. So, this year I will do my best to explain the Internal Medicine residency process for those who may be curious.

1st year= Intern year. We are "residents" for all 3 years of residency but the first year we have the special (and not in a good way) designation as "interns". Interns do all the work. We have a saying that if the residents and attending physicians (our bosses) were not in the hospital for a day the patients would do just fine, but take away the interns (and the intensive care nurses) and things would fall apart. Poor interns. It's terrible to be an intern. I will never have to do that again.

2nd year= 3rd year= Senior Resident. The residents are in many way the team leaders. They watch over the interns, sub-interns (4th year medical students) and 3rd year medical students to make sure the patients are taken care of appropriately and to ensure all the daily work gets done. They also run daily rounds and often have to "manage up" to help the attendings stay on task and efficient. I'll go into detail about that role when I'm "on service" which means on a block where we have a set of inpatients we are responsible for.

Right now, on Palliative Care, I'm not "on service". Which is great, because that means I generally get my weekends off and for the most part am home by 5pm. For me, Palliative Care is an elective month, meaning I chose it. All residents have to do at least 2 weeks of Palliative Care. Since end-of-life care is a big interest on mine, I'm doing a total of 6.

So what is Palliative Care? It's a fair question and one that most physicians don't even know how to answer. In the broadest sense, Palliative Care is the art of working to prevent and relieve suffering from (a wide array of) symptoms. There are many diseases that we can't "cure" and other diseases where the only hope of "cure" comes at the expense of difficult treatments that produce a lot of symptoms (chemo comes to mind here). Most diseases in this day and age are chronic diseases. From heart failure to HIV to renal failure to many cancers, we can manage and treat the illness allowing people to live for many years with the disease still present in their bodies. This results in folks living logner lives but also results in a lot of daily symptoms such as pain, nausea and shortness of breath that patients must contend with.

The Palliative Care consult team is called to help address these symptoms. Pain is the most common symptom we help address. From headaches to post-surgical pain to sickle cell crises to existential pain, we're a one-stop shop. There is a lot of confusion and hesitancy around dosing narcotics, so we often help with that. Another common symptom is nausea. Other consults we've had in the past 3 weeks have included: constipation, shortness of breath, intractable hiccups, and painful coughing fits.

A sub-component of Palliative Care is end-of-life care. At the end-of-life folks can have a lot of symptoms, most commonly pain, shortness of breath and agitation, that we can very easily prevent and treat so that everyone can have a comfortable death. I think helping patients have comfortable, pain-free, deaths is the most important thing I can do as a physician.

Our consult team, however, does way more than swoop in and treat symptoms at the end-of-life. We are very involved in goals of care conversations in which we help patients and families think about what they want for themselves or their loved ones when it becomes clear that their disease is not going to be cured or even held at bay much longer. The days where I have heart to heart conversations with patients and their families about their priorities at the end-of-life are the days I feel most like a physician. They are also the days when I feel like I've actually made a difference in the world.

Our society does a terrible job of discussing death and dying. For some reason, we are afraid of talking about the end of life. As a result, most families fail to discuss their personal wishes at the end of life leaving their family wondering "Would they want to be hooked up to a ventilator?", "What kind of quality of life would be 'worth living' for my loved one?", "At what point would my loved one want to 'let go' and disconnect all the tubes, IVs, breathing machines keeping their heart pumping and their lungs filing with air?".

Thus, we end up with ICUs (intensive care units) full of very sick patients with 'multi-system organ failure' (meaning 3 or more of their organs have completely stopped working) who have absolutely no quality of life and, quite frankly, may be suffering. It is our job as the Palliative Care team to step in and help the family process what is happening, and help them to think hard about what their loved one would want. Often times, after serious reflection, families realize it is time to "let their loved one go" and we begin to focus on comfort care --> ensuring the patient is comfortable but no longer focusing on prolonging their life.

The Palliative Care team also helps facilitate hospice. Hospice means many things to many people. At it's core, hospice is a philosophy about the end of life, that focuses on comfort and quality of life over quantity (or duration) or life. Hospice is a philosophy but it is also a program that is designed for any person who has a life expectancy of less than 6 months. Hospice programs provide specially trained doctors, nurses and social workers to help patients die with dignity in the setting that serves them best. For many people, home is where they would like to spend the last days/weeks/months of their lives and home hospice programs make this possible by providing visiting nurses, supplies and training for the family to take care of dying loved ones at home. On the Palliative Care consult team, we help facilitate the transition to home hospice for appropriate patients.

I hesitated in writing this post out of concern that it may all sound very depressing. But I want to assure you that, while sad and poignant, helping patients decide how and where to live out their final time on this Earth is the most rewarding and humbling experience I have the privilege of being involved in as a physician. We all die. Some of us expectedly, some of us unexpectedly, some at a nice ripe old age and some way too soon. We should all live our lives with no regrets in case we are members of the unexpected and too soon category. And we should device a society that knows how to provide a good death for all people and their families so that death can truly be a celebration of a person's life rather than a scary secret occurrence that makes us all uncomfortable. Our medical science is so advanced that we can keep people alive (though with no quality of life) nearly forever. My hope is that we are able to step back and look at the big picture of every individual's life and know when it is time to let go. That's my most important job on the Palliative Care service, and as a doctor.

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