Editorial - (2015) Volume 0, Issue 0
| Douglas Trenkle1* |
| Corresponding Author: Douglas Trenkle,American Board of Internal Medicine, American Board of Clinical Lipidology, 651 Morgan Bay Road, Surry, Maine 04684, USA,Tel: 207-461-6724 E-mail: douglas.trenkle@gmail.com |
| Related article at Pubmed, Scholar Google |
In our book club we read all sorts of literature. On one occasion we even took turns reading a Shakepearean comedy, “Much Ado about Nothing.” But our last reading was more serious, and was “Being Mortal” by Atul Gawande. It is a very good story by this fine physician, reporting on the dilemmas we face with aging, illness, and dealing with death as it approaches to end our life. It also had a very personal part, as Dr. Gawande told the story of his own father, a physican also and now deceased, who had a paraspinal tumor causing symptoms. One doctor said to operate soon, another said to wait there was no hurry. How could this be? Diametrically opposed opines on a spinal cord tumor presented by their consultants… The Gawandes were confused and upset in this circumstance, and both had backgrounds to understand pathophysiology and treatment of disease. One can only imagine the confusion to lay people who have litle or no background, only Google.
Description |
| In our book club we read all sorts of literature. On one occasion we even took turns reading a Shakepearean comedy, “Much Ado about Nothing.” But our last reading was more serious, and was “Being Mortal” by Atul Gawande. It is a very good story by this fine physician, reporting on the dilemmas we face with aging, illness, and dealing with death as it approaches to end our life. It also had a very personal part, as Dr. Gawande told the story of his own father, a physican also and now deceased, who had a paraspinal tumor causing symptoms. One doctor said to operate soon, another said to wait there was no hurry. How could this be? Diametrically opposed opines on a spinal cord tumor presented by their consultants… The Gawandes were confused and upset in this circumstance, and both had backgrounds to understand pathophysiology and treatment of disease. One can only imagine the confusion to lay people who have litle or no background, only Google. |
| In “Being Mortal” Dr. Gawande describes complex contradictions in aging and end of life care, yet he never mentions the importance and impact of law suits on doctors. In a word, litigation. As an internist and having been in primary care, making hundreds and perhaps a thousand or more of house calls in my career, I saw an aspect of the revolving door we call life. And it is through this door we pass from life to death. Gawande mentions that 40% of oncologists prescribe chemotherapy that the doctor does not believe will work. And beyond these medical therapies that are given us to prolong our lives, there are the technological interventions that are proven to benefit only a few for a few years, namely, percutaneous intervention for heart attacks. The list is possibly endless, but I think those two points say a lot about what is done for people. The question however, is, “Why is this being done?”. |
| Well, it is an age old story, we become ill, and as a patient, often with family, we say to the doctor, “Doctor, can’t you do something?” The answer always, or almost always, is “Yes,”…but whether that intervention is beneficial is another story. In my experience oftentimes the treatment only delays death, at the expense of prolonged suffering of the individual. |
| I recall when my mother was diagnosed with metastatic adenocarcinoma from an unknown primary, and her oncologist, pulmonologist and internist all told her to take chemotherapy. The only time in her life she ever asked me for advice, she asked what she should do. I said, “Mom, do nothing.” So I flew to Pittsburgh to visit her, and she asked me to speak with her oncologist at the university. I called him, and here is how the conversation proceeded. “Hi, this is Doug Trenkle. My mother asked me to call regarding my opinion to defer chemotherapy.” The oncologist, whose name I don’t recall said, “Yes, why did you not want her to get treated?” I then proceeded to quote a double blind study from NEJM of 240 patients who had my mother’s diagnosis, and the treated group lived, on average, a month less than the untreated… and the life expectancy was only a couple of months. I could not recall the exact issue, but this doctor quoted it chapter and verse. “Oh yes,” he said, “that was an important study by so and so.” Further I inquired, “Doctor, knowing this, why are YOU recommending therapy for my mother that has been shown to not be beneficial?” He responded with ananecdotal story about a minister’s wife who survived liver cancer he treated once. “Thank you doctor”, and I said good bye, and hung up the phone. My mother lived 15 months, was never in a hospital, died with hospice care at home, and avoided all the complications that would have followed the unfortunate recommendation of all three of her doctors. I knew at the time my advice was correct, if not just loving. What was unclear to me was why this and other “experts” had recommended chemotherapy(s) for my dear mother. |
| The question remains unanswered, “Why?” But I think an answer is evident and has a complex fabric. First, there is the fear of being sued for not doing enough. Gawande never mentions this in his work. And litigation is a major factor that pushes us to intervene when we should be providing a realistic opine of the patient’s state, and his or her future. Those opportunities arise and can only be broached when there is a caring and fully competent physician who understands and can empathize. That is the time to begin to discuss supportive and palliative care measures. No question about that. But there is another conflict, and it is more difficult to define but certainly is a place where doctors are put in a conflict of interest, and that is when doctors are rewarded monetarily for their treatments and interventions. Doctors are in the business of caring for people, but they can have this conflict of interst when they are in research, or have a particular interest in certain treatments in terminal or serious illness. The course with chemotherapy and radiation makes people (us) so ill with a host of complications, and oftentimes with little or no benefit. Lumpectomy and radiation to the breast has no better survival than simple mastectomy/reconstruction for the woman with breast cancer. But the former is almost always recommended, rather than the latter. Aside from cancer care, we also know, for instance, that percutaneous interventions for heart attacks only prolong life in a small subset of affected individuals with acute cardiovascular disease, and that benefit is short lived, at most 2 years benefit. And PCI, like radiation therapy, is expensive. |
| We need to listen, and to speak clearly to our patients. We need to be fully linformed, competent, but also to care for them and their condition. “Doctor, is this illness going to take my life?” “How so?” “How long, usually?…” “Is there much to suffer or can that be alleviated?” “If I am treated, how often will there be complications requiring clinic or hospitalizations?” These are the most important questions for us to have clear in our minds as we approach patients with major decisions in their life. And I hope that all of us provide our patients the appropriate answers. |
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