Most doctors avoid saying it's the end.....

[cougarnurse]

I think this is a shame: Most cancer doctors avoid saying it's the end - Yahoo! News
We need more who know when to refer to Hospice.
CHICAGO - One look at Eileen Mulligan lying soberly on the exam table and Dr. John Marshall knew the time for the Big Talk had arrived.
He began gently. The chemotherapy is not helping. The cancer is advanced. There are no good options left to try. It would be good to look into hospice care.
"At first I was really shocked. But after, I thought it was a really good way of handling a situation like that," said Mulligan, who now is making a "bucket list" — things to do before she dies. Top priority: getting her busy sons to come for a weekend at her Washington, D.C., home.
Many people do not get such straight talk from doctors, who often think they are doing patients a favor by keeping hope alive.
New research shows they are wrong.
Only one-third of terminally ill cancer patients in a new, federally funded study said their doctors had discussed end-of-life care.
Surprisingly, patients who had these talks were no more likely to become depressed than those who did not, the study found. They were less likely to spend their final days in hospitals, tethered to machines. They avoided costly, futile care. And their loved ones were more at peace after they died.
Convinced of such benefits and that patients have a right to know, the California Assembly just passed a bill to require that health care providers give complete answers to dying patients who ask about their options. The bill now goes to the state Senate.
Some doctors' groups are fighting the bill, saying it interferes with medical practice. But at an American Society of Clinical Oncology conference in Chicago earlier this month, where the federally funded study was presented, the society's president said she was upset at its finding that most doctors were not having honest talks.
"That is distressing if it's true. It says we have a lot of homework to do," said Dr. Nancy Davidson, a cancer specialist at Johns Hopkins University in Baltimore.
Doctors mistakenly fear that frank conversations will harm patients, said Barbara Coombs Lee, president of the advocacy group Compassionate Choices.
"Boiled down, it's 'Talking about dying will kill you,'" she said. In reality, "people crave these conversations, because without a full and candid discussion of what they're up against and what their options are, they feel abandoned and forlorn, as though they have to face this alone. No one is willing to talk about it."
The new study is the first to look at what happens to patients if they are or are not asked what kind of care they'd like to receive if they were dying, said lead researcher Dr. Alexi Wright of the Dana-Farber Cancer Institute in Boston.
It involved 603 people in Massachusetts, New Hampshire, Connecticut and Texas. All had failed chemotherapy for advanced cancer and had life expectancies of less than a year. They were interviewed at the start of the study and are being followed until their deaths. Records were used to document their care.
Of the 323 who have died so far, those who had end-of-life talks were three times less likely to spend their final week in intensive care, four times less likely to be on breathing machines, and six times less likely to be resuscitated.
About 7 percent of all patients in the study developed depression. Feeling nervous or worried was no more common among those who had end-of-life talks than those who did not.
That rings true, said Marshall, who is Mulligan's doctor at Georgetown University's Lombardi Comprehensive Cancer Center. Patients often are relieved, and can plan for a "good death" and make decisions, such as do-not-resuscitate orders.

"It's sad, and it's not good news, but you can see the tension begin to fall" as soon as the patient and the family come to grips with a situation they may have suspected but were afraid to bring up, he said.
From an ethics point of view, "it's easy — patients ought to know," said Dr. Anthony Lee Back of the Fred Hutchinson Cancer Center in Seattle. "Talking about prognosis is where the rubber meets the road. It's a make-or-break moment — you earn that trust or you blow it," he told doctors at a training session at the cancer conference on how to break bad news.
People react differently, though, said Dr. James Vredenburgh, a brain tumor specialist at Duke University.
"There are patients who want to talk about death and dying when I first meet them, before I ever treat them. There's other people who never will talk about it," he said.
"Most patients know in their heart" that the situation is grim, "but people have an amazing capacity to deny or just keep fighting. For a majority of patients it's a relief to know and to just be able to talk about it," he said.

Sometimes it's doctors who have trouble accepting that the end is near, or think they've failed the patient unless they keep trying to beat the disease, said Dr. Otis Brawley, chief medical officer at the American Cancer Society.
"I had seven patients die in one week once," Brawley said. "I actually had some personal regrets in some patients where I did not stop treatment and in retrospect, I think I should have."
James Rogers, 67 of Durham, N.C., wants no such regrets. Diagnosed with advanced lung cancer last October, he had only one question for the doctor who recommended treatment.
"I said 'Can you get rid of it?' She said 'no,'" and he decided to simply enjoy his final days with the help of the hospice staff at Duke. "I like being told what my health condition is. I don't like beating around the bush," he said. "We all have to die. I've had a very good life. Death is not something that was fearful to me."
Mind you, I like how Mr. Rogers put it: We all have to die. Sad, but true. I'd like to go out with dignity. Any thoughts or comments?

[cassioo]

When my dad was dying last year this time he was in the hospital for the 2nd time in 2 weeks My parents asked about hospice and the doctor told them no he didn't think it was time and he looked better then he had at his visit 4 days prior (he didn't) and then told him there was some experimental treatment in St Louis (4 hours away) and maybe dad could try that he was almost 77 then...well that got his hopes up he went home for about 4 more days then back to the hospital by ambulance spent 3 weeks in the hospital getting TPN and blood, chest tubes and an infection. He came home on a Friday and died in the early morning hours of Sunday and felt like crap those last few weeks. I didn't think much of that doc in the first place after that I just want to kick his chair when I see him at work now.

[cougarnurse]

Maybe you still should? Maybe he needs a copy of this article....

[Ricu]

Hi folks,

This article is very timely. Actually, it's long overdue. The feature affliction is cancer but it is common now that people are living with several progressive diseases which are also terminal. So often they slog on with yet more prescription and no discussion about care options or even DPOAH from the doctor. What's appaling is that once again, the law is dictating medical practice- but somebody has to do it. Physicians in general, DO avoid end-of-life discussions which consequently leaves the patients and their loved ones to spend those precious final hours coming to terms with the fact that disease does become terminal and that ths IS the end rather than focusing on the loved one who is moving on.

Cat, you asked me a few months ago whether I had any ideas for a new thread, how about Palliative Care? I've spent many hours over the last few years doing palliative care nursing in the critical care setting and during the last year, a physician with this specialty joined our hospital staff. What do you think?

R

[cougarnurse]

Sounds great to me, RICU!

[OldSquidNewNurse]

There have been a number of studies done that show the unnecessary costs involved in treating people in the last month of life when there was little or no chance of a meaningful recovery.

[cougarnurse]

It's been several years since my maternal Grandmother died; the dx was end stage CHF. She had stated she lived a long life, and had outlived her 2 sisters and younger brother (she was the 2nd oldest kid). Luckily, she passed 'quickly', and the kids (my mom, aunt, and uncle) had all agreed on Hospice. We are fortunate in that our family doctor is pro-Hospice.

Perhaps it is because there have been so many break throughs in health care. In Gram's life time, there has been the discovery of antibiotics, insulin, vaccines..... Remember JFK's son, Patrick died from Hyalin Membrane disease; now, preemies are given a chance to live. Just food for thought.

[ICUruthie]

I agree to all of the above. I had a patient last week in the cardiac ICU- 85 yr old female. Bypass and heartvalve surgery performed- multiorgan failure after this.... STILL for days the doctors kept pressing on and even giving false hope to patient family. Frustrating when you see the patient integrity being compromised..... Why is it so difficult for the doctor to realize it is time to let go? Finally after persuasion by nurses, we ended up letting her go. A relief for both family and it ended up just being a beautiful and peaceful time.......

[cougarnurse]

Doesn't a doctor swear to 'First, do no harm'?????

[debic1965]

I have had doctors refuse to give orders. One even said "give her whatever the (bleep) she wants" when I called for pain meds. Pain management is crucial for many dying patients. Personally, I find it a privilege to walk my patients/residents/clients home. Dignity, respect and comfort are what I look at. I realize some doctors take it personal when they lose their patients but why prolong things when quality is in many of these cases better than quantity. I just "walked" one of my residents home last weekend. It was sudden, but he did not die alone and he had family there. I remained until Hospice came in. It was peaceful.