Healthcare Professionals Blog

By Dr. Jonathan Weinkle

A pair of healers, one an experienced teacher of medicine, the other a freshly-minted intern, reflects on the transforming power of the third year of medical school in the recent piece, “Into the Water – The Clinical Clerkships.”  

The intern, Neal Chatterjee, describes the jarring, unnatural moments that punctuated his third year, and concludes that the experience is, “like being thrown head first into water,” only to eventually become such an adept swimmer that one is unaware of the water at all.  His teacher, Katherine Treadway, turns this acculturation on its head.  During that “power and turmoil,” the “high level of compassion with which students enter medical school” begins its well-documented sharp decline.  “It is ironic,” says Treadway, “that precisely when students can finally begin doing the work they . . . came to  . . .  do . . . they begin to lose empathy.”

Less is more – and sometimes more is less.
With our healthcare system in crisis mode, it seems like sheer fantasy that we could deliver more care and actually spend less money.  But according to an article in the March 2011 issue of Health Affairs, the use of high-quality palliative care in seriously ill patients might actually make that fantasy a reality.
The study looked at Medicaid-insured patients in four hospitals in New York state (New York City, Rochester, and Buffalo) who had a range of life-limiting illnesses.  It compared patients who had received palliative care during their hospitalization to patients who had the same condition but had only received “standard care.” 

Last month the American Society for Clinical Oncology (ASCO) published a statement in the online version of the Journal of Clinical Oncology, entitled, “Toward Individualized Care of Patients with Advanced Cancer” (http://jco.ascopubs.org/content/early/2011/01/24/JCO.2010.33.1744.full.pdf+html) It reads almost as if one of the staff of Closure had written it.
ASCO suggests a radical change to the way cancer care is delivered.  The change begins with candid conversation about the person’s diagnosis and prognosis soon after the discovery of the cancer, when enough time remains to make clear-headed decisions.  It continues with offering palliative care to enhance the quality of life right from the start, even while providing the best curative treatments available.  It includes allowing the patient to weigh in on the goals and the course of treatment at every point, to change her mind, to opt out, or to seek alternatives.  It concludes with offering hospice care when curative options run out, while there is still time to die in peace and dignity.

A recent New York Times article fretted about the possibility that “For-Profits May Be Cherry-Picking Hospice Patients” (http://www.nytimes.com/aponline/2011/02/01/health/AP-US-MED-Hospices-Profit.html?_r=3&ref=health).   The concern was that for-profit hospices, which have been found to have longer lengths of stay and higher numbers of patients who survive for an extended period on hospice than do nonprofit hospices, are selecting the “easier,” less-costly patients to make a greater return on the daily Medicare reimbursement of $143 per day.

As far as we have come in medicine we have not defeated death.  Death is neither a medical error nor a failure of will by the doctor or the patient.  We can postpone it but not eliminate it.  We can anticipate it – but more often we try to avoid or deny it.  When we cannot sidestep, and must face death, we often panic.

To every intern asked to “get a code status” for a patient he or she has never met, to every doctor who has been asked by the family of a dying patient, “What should we do?” and not known how to answer, and to every nurse or therapist who has felt helpless in the face of a dying patient’s pain, we dedicate www.closure.org for Health Professionals.

Here you will find guidance for having the difficult conversations so that your patients and their families say what they really need to say – and so that you really hear them.  You will learn tools for giving comfort when you cannot give cure – and to increase comfort while you are trying to cure.  You will acquire strategies for setting goals and making decisions as a part of a team with your patient so that you can honor his wishes, whether those wishes are for a peaceful, quiet death or for a determined battle to survive in the face of overwhelming odds.  You will learn not to wait until it is too late.

The Closure Web site offers hope – hope that while we wish long, healthy lives to everyone, the final chapters of those lives can be filled with peace and fulfillment, rather than pain and suffering.  Join us and learn what you can do for your patients.

Since our Web site is new, we are interested in hearing your thoughts and ideas so that we can better enhance your online experience. Have a suggestion for a topic you think we need to cover? Do you know of some additional resources we could use? Let us know your thoughts by responding to this blog post.

The Closure Team