Friday, November 30, 2012

The Wisdom of a Dying Physician

Viewed from this side of the Atlantic, the controversy playing out in the United Kingdom over the Liverpool Care Pathway is as familiar as it is perplexing. It is in the United States, after all, where certain politicians and media have made it controversial for Medicare policy to pay physicians to discuss their end-of-life wishes with patients. This makes no sense, discouraging literally vital dialogue, and making it more difficult for physicians to built relationships of trust with patients.

Don’t take it from me. Listen to Dr. Kate Granger: “It is not fancy technologies or complicated research that is going to fix the problem. It is quite simply some good quality talking and a culture and environment that allows this to happen.”

Dr. Granger is a physician in the United Kingdom. But she is also a patient, one with a terminal cancer diagnosis, “musing about life & death” on her Wordpress blog.

She writes: “One of the reasons I have been so open about my own dying both in public and in private with those I love is that I believe openness is inextricably linked to achieving ‘a good death’ and perhaps more importantly ‘good grief’ for those left behind.”

Most recently, Dr. Granger has become troubled by a spate of negative press coverage in the UK about the Liverpool Care Pathway, a widely adopted means of addressing the wishes and best interests of a dying patient that has been around for a couple of decades, but has only now become controversial. It has been irresponsibly cast, in terms that will be familiar to followers of America’s “death panel fear-mongers,” essentially as a vehicle of patient abandonment for financial reasons. It has become known to some media as the "death pathway."

Dr. Granger writes of “a perception more and more that everything done in the (National Health Service) is underpinned by monetary factors, bed pressures and lack of resources and that these issues motivate us as doctors rather than our patient’s best interests.” This, she writes, is “something I find very sad as I go to work primarily to look after people.”

As Dr. Granger notes, it would appear that recent failings of the LCP stem not so much from the program itself, which has an impressive record of compassionately allowing terminal patients to die, as desired, with dignity and at home. The failings are in communication.

“The irresponsible handling by some of the media has left us as clinicians in a hugely difficult and worrying place,” she writes. “As a doctor I would hope that the relationship I have with my patients and their families is based on a solid foundation of trust; a trust that I am there solely to act in their best interests and to care for them. As a patient myself I trust my own GP and Oncologist implicitly. But when the press and sometimes the politicians start to undermine this trust then we are left in an extremely worrying and dark situation.”

Dr. Granger’s solution: involving palliative care specialists earlier. As in the US, palliative care has been shown in the UK to improve quality of life for a terminal patient, and even to add time.

“I do not believe the problem itself has anything to do with the actual LCP,” Dr. Granger writes. “I think the solution is really very simple and yet difficult to achieve. When someone is diagnosed with a condition that is going to limit their lifespan such as heart failure, dementia, metastatic cancer or MND for example I believe early, open and honest discussion about prognosis is a necessity. This allows the patient choice and some degree of control over what will happen in their life.”

And communication with a patient is just one aspect of the palliative speciality.

“In my model the Palliative Care practitioner would be in the clinic when the patient is first diagnosed and work in partnership all the way with that patient,” Dr. Granger writes. “I am reminded of a quote from Dame Cicely Saunders, the founder of the hospice movement: You matter because you are you, and you matter until the last moment of your life. We will do all we can, not only to help you die peacefully, but also to live until you die.


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