Do not Relegate Palliation

Adam’s post yesterday stirred me to write about the words and intentions doctors use. Do read his column. I’ve read it three times.

The story centers on the care of an elderly man nearing end-of-life. These are the hardest treatment decisions I make—bar none.

I blame innovation. When I started Medicine, end-of-life decisions were easier because there was so much less to do. Now, there is almost always something to do.

I tell young doctors that their biggest challenge will not be having something to do for a person but whether you should do it.

The tension for a subspecialist is that older patients almost never have one problem to fix. An ablation can fix a tachycardia, but the person still has dementia and immobility; a pacemaker can fix bradycardia, but the patient still has oxygen-dependent lung disease and cancer.

The thing is…these patients are in the dying process, but if you don’t fix tachycardia or bradycardia the patient does not die in weeks or months but in hours to days. As specialists, we usually don’t know this person or the family—yet we are faced with the decision to operate or not. And that decision directly bears on the length and quality of their remaining life.

Our team walks out of such a person’s room and we stare at each other. No words are needed to express the tension. Tension because all of us love what our procedures can do but we also know the limitations of these procedures and that you can’t just fix people by turning knobs on a machine.

This is where our words and intentions enter the mix.

Adam writes, correctly, that the phrase “we have nothing left to offer,” is an easy way out and leaves the patient feeling abandoned. Indeed I hate that phrase more than any other, because, of course, caring counts as having something to offer.

But then Adam argues that we should not be so afraid to say we have nothing to left to offer beyond palliation. (Italics mine). It’s that last adverbial phrase beyond palliation that stirred my brain.

I don’t think palliation should be so relegated. The frame Adam implies here is the patient with a growing tumor that no longer responds to chemotherapy. The correct answer is to stop giving ineffective harmful medicines and control this person’s pain and relieve suffering as much as possible. You hope that there is access to a team of palliative care specialists who can guide this care; but even if there is not, all doctors should have some skill in the relief of pain and suffering.

But I have two more things to say about the beyond palliation relegation.

First, since 100% of humans will eventually die, and many will suffer greatly during the dying process, I don’t understand why we would think therapies to relieve suffering should be relegated to less important than drugs or surgery. Yes, of course, it’s nice that we can extend life with a new drug, but there is so much to celebrate when a patient and family can suffer less when the inevitable comes. This may be one of the highest value propositions in all of Medicine.

The second reason to not relegate palliation is that palliation forms the core of modern-day medical practice. Sure, appendicitis and supraventricular tachycardia can be cured with a procedure, but these are the exception not the rule.

Far more common is the everyday conditions that we palliate. Blood pressure and diabetes medications, inhalers, coronary stents, heart valve replacements, atrial fibrillation ablation, dialysis, and maybe a hundred other therapies are palliation.

We palliate so much that we are like fish who don’t notice water.

Now that I have made the case for keeping palliation on equal ground to all medical therapy, I suspect you expect some lofty conclusion about how to handle complex older patients with serious disease.

Here I will disappoint you. There is no easy solution; no algorithm. Patients and families and conditions vary so much that it would be foolish to even think Claude or Chat GPT or an expert guideline could help.

There is however one guiding rule. Adam shows it in his conclusion. He allows his patient to come in to visit. Both know that there are no cures; Adam offers advice. The patient will not likely take it. Which is fine.

The underlying tenet was that the patient got to choose what was best for him.

Perhaps the mistake I make most often is too strongly transmitting my idea for what is best for the patient with serious disease. For some people, not putting in a pacemaker or stopping their statin is fine; for others, withdrawing anything is distressful.

What I am learning—slowly—is that we allow our patients to control as much as they want to control.

This is palliation done well and there is no need to relegate it as a lesser intervention.

JMM