Need for a different mind-set is vital (part 2 of 5) Oncological (cancer) care has much to offer in cancer cure and significantly improves the length of survival. When these goals are beyond reach, cancer care should be coordinated with Palliative Medicine which is a board-certified specialty, practiced in many hospitals. Palliative care specialists have a good feel for the life-expectancy of end-of-life patients, contradicting an-often repeated comment, "We have no idea when the patient will die." The over-riding goals at the end-of life are the patient’s comfort and ability to function, both physically and mentally. The question of how long a terminal patient lives is superseded by answers to these two questions: “How would the patient like to live?” and “How would the patient like to die?” I have a hard time reconciling a high-technology hospital with a highly-skilled staff providing high-cost care to a patient whom everybody accepts is not going to get well. The patients are often admitted to the hospital for a variety of pressing reasons and cannot be discharged for a host of non-medical issues. Instead of providing a holistic care for patients and their families, care-givers are often “zeroed in” and “bogged down” with investigating and managing multiple biochemical, radiological or clinical abnormalities (including providing intensive care). These are some of the reasons why the cost of care per person in the U.S.is twice that in countries of comparable economic status. The U.S.spends 17% of its GDPon healthcare; which is between 30% and 50% more than other countries with whom we compete economically. Palliative Medicine specialists, who care for end-of-life patients, along with the patients’ primary care provider, are under-utilized because patients and families do not desire to confront the over-all picture. Yet, busy cancer specialists are unlikely to have the patience, temperament or set-up to achieve a different set of benchmark end-points. Conflict of interest poses another dilemma. High technology and intensive care is a poor substitute (if not an added burden) for emotional fulfillment at the patient's (and the family's) most critical period in life. Studies of the current practice highlight the present system’s pitfalls. These include poor comfort care (part of this discomfort is treatment-related); lack of adequate communication between healthcare providers, patients and their families; treatment decisions that in hindsight are contrary to the wishes of the patient, family and good medical practice. These factors are also detrimental to overall care. This whole experience is traumatic to all involved, with long-lasting residual effects on the surviving relatives and care-givers; that run the risk of ‘burn-out’. As a society, we have tried to remedy this with legal documents such as "Living Will" and /or "Healthcare Proxy" and / or "Advanced Directives" etc. While these are all good, they are a poor substitute for family dialogues, bonding and a common-sense approach to a challenging problem; which barely existed a generation ago. It is imperative that patients, their families and doctors have an on-going dialogue on the issue of end-of-life care, including philosophical and practical issues, and come to some understanding of what should and should not be done, long before the situation is at hand. Helping the patient and family come to terms with the over-all perspective of their situation is an ongoing process that cannot be rushed nor ignored. Today’s society is a dispersed distribution of first and second degree relatives. To bring all on-board, while leaving behind ‘old baggage’, needs perseverance. Patients with widespread disease who fail the first-line of therapy should be introduced to the hospital's palliative care team to develop a relationship between the patient, family, oncologist and palliative care specialist. The on-going four-way dialogue will establish an intellectual (scientific and objective) and emotional grounding for the times when difficult decisions have to be made. While the oncologist and other specialists are disease-focused, the palliative care team is patient-centered and focuses on the philosophical, religious, and social-cultural values of the patient and family. The team pays special attention to the basic needs of the patient and family, while weeding out extraneous factors which are of little short-term and long-term consequence. A palliative care team includes the physician, a nurse, social worker, psychologist, nutritionist, pastor, and patient navigator, with each (as needed) having a continuing relationship with the patient and their home-care nurses. Cost of End-of-Life Care (part 3 of 5) next Regards, GL
