Respectful Insolence

OK, I know it’s like the post calling the kettle black, but what the heck is PalMD doing blogging on vacation? And are his two most recent posts so good? This is what I mean:

I recently had the unfortunate opportunity to visit a relative in hospice. I was incredibly impressed. Nice, well-appointed rooms, with a caring, attentive staff that did everything in its power to keep the dying as comfortable and free of distress, both physical and emotional, as humans can do. As a cancer surgeon, I’ve been involved with a number of patients who went to hospice, and I can only hope that the hospices they ended up going to were as good as this one.

Another point that PalMD makes that’s spot on is about telling a patient that they might have cancer. This is a task that is commonplace in my specialty, and, worse, it’s breast cancer, which has all sorts of added baggage attached to it than most other kinds of cancer. Women often see me because either they have felt a lump in the breast or because their mammogram was read as possibly suspicious for cancer. Once the “C” word is uttered by a physician, often little else is heard, even the part about its being only a 20% chance that there’s cancer (a typical number for most abnormal mammograms that require a biopsy). As for having to tell a woman that she has breast cancer, that’s never an easy task. Fortunately, though, I can usually offer hope. Most of the breast cancer that I diagnose as a surgeon is potentially curable, and early stage breast cancer is over 90% curable. I can offer hope to women in these cases and receive in return the satisfaction of curing them, which is one reason why this specialty can be so rewarding. Even in the case where the cancer has metastasized, treatments have improved to the point where women can sometimes go years without much progression of their disease; so even in such cases, although neither I nor anyone else can cure the patient, at least I can still offer hope.

I may have to write about this in more detail sometime soon, as PalMD’s reminded me that I have been wanting to do a post about this topic for a while now.

In the meantime, PalMD should spend more time on the beach. I know, I know, I’m about as bad an example as can be had, but maybe I’ll change.

Or maybe not.

Comments

#1 sirhcton
May 5, 2008

My family’s experience with hospice care was born out by the comment of the physician who suggested it. They said hospice would be the easiest part of the medical bureaucracy to deal with we would ever encounter. That turned out to be true in every respect, including the care and counsel provided.
#2 Beauzeaux
May 5, 2008

In my experience, Hospice programs are not primarily in-patient. The goal of hospice is to make it possible for people to spend their last days at home. In-patient beds are made available for pain management, respite for caregivers, and anything else that is difficult in a home setting.
I was a hospice volunteer and it was a great experience. A lot of fun, too. Hospice is about life — living every day to the fullest. I recommend it to everyone. I’ve never known anyone who regretted getting hospice in. In fact, they all say: “I wish I’d called them sooner.” (The doctors and nurses are truly wonderful. Only the BEST medical people gom into hospice work.)
#3 FullFrontal
May 6, 2008

PalMD’s posts have been great. He must have a more tolerant better half than I do; I don’t think I’d get away with as much blogging on vacation as he has.

In pediatrics, the AAP and other agencies are looking at Hospice in new ways. While children can certainly benefit from hospice care, we’re finding that few receive it. This is almost certainly due to a combination of factors. It’s often next to impossible for the treating pediatrician to state that a child with a healthy heart and lungs will die in the next six months. Couple that with parental refusal to accept the statement and you have a lot of kids not benefiting from the care. Another factor that often complicates the issue in peds (not sure if this creeps into adult hospice) is that many of the interventions would in any other circumstance be considered active treatment but in peds are often considered palliative (e.g. positive pressure ventilation to alleviate dyspnea or low dose chemo to reduce tumor symptomatology).

In pediatrics the move is toward a model of palliative care. For inclusion, the child can be suffering from a life threatening or terminal illness. A child can be eligible even if undergoing aggressive treatment for the primary illness. Other interventions provide comfort for the ill child and his/her family, especially young siblings. Most major government payers have been mandated to develop a plan for payment of palliative care services for children. I know this is happening in my state–it’s currently being piloted in several counties. The going is slow but it’s an inevitability I think. The AAP has a nice summary of palliative care–here’s the link:

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;106/2/351
#4 Abel Pharmboy
May 6, 2008

On the lighter side of things, I think Pal is in a place where there’s lots of water but not so much beach. Hence, he probably has more time than one might think in settings where there are internet connections. I often think much more clearly on vacations (and, no, the extra alcohol consumption has nothing to do with it) and maybe he just has more time now to think about things he really cares deeply about.

So, yes, two really good posts from him and I also appreciate you sharing your experiences with us. Reminds me of how hard your job is and that, yes, even our doctors suffer personal losses.