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Role and Responsibility of the Physician in Palliative and End-of-Life Care: The Interdisciplinary Team Approach

Why do we need to talk about this?. Recent national studies indicate that physician skills are suboptimal in:Symptom controlEnd-of-life communication. . How we rate on control of pain:. A recent large multi-center survey of patients with metastatic cancer and severe pain revealed that 42% were NO

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Role and Responsibility of the Physician in Palliative and End-of-Life Care: The Interdisciplinary Team Approach

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    1. Role and Responsibility of the Physician in Palliative and End-of-Life Care: The Interdisciplinary Team Approach University of Maryland School of Medicine Introduction to Clinical Practice Freshman Course

    2. Why do we need to talk about this? Recent national studies indicate that physician skills are suboptimal in: Symptom control End-of-life communication

    3. How we rate on control of pain: A recent large multi-center survey of patients with metastatic cancer and severe pain revealed that 42% were NOT GIVEN ADEQUATE PAIN THERAPY!* Cleeland, et.al., NEJM 330:592-6, 1994

    4. The SUPPORT Study (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment) JAMA 274:1591-1598, 1995 Objective: To improve end-of-life decision making and reduce the frequency of a mechanically supported, painful and prolonged process of dying Eligibility...patients at high risk for death 50% mortality overall Phase I: 4301 patients observed Phase II: randomized, controlled trial of an intervention (4804 patients)

    5. SUPPORT: Phase I Results 70% of patients or surrogates had no CPR discussion with physician... Physicians were not aware of their patient’s desire for DNR in 53% of cases 50% of patients had moderate to severe pain during their last 3 days Half the patients spent a week or more in an ICU, coma or on a ventillator 31% of families lost all or most of their savings during the patient’s final illness

    6. Main Conclusions of SUPPORT: too often we die alone, in pain, attached to machines the system doesn’t know when or how to stop Prognosis--we often don’t know until it’s too late when an illness is fatal when someone is dying may have to accept some ambiguity...

    7. Suffering in Children with Terminal Cancer Wolfe, et.al. NEJM 342:326-33, 2000 Interviewed 103 parents of children who died of cancer (1990-97) 80% died of progressive disease 49% died in the hospital 50% of these were in an ICU 89% of children suffered “a lot” or a “great deal” in the last month

    8. Why don’t we do a good job? We were never taught in medical school! Most schools do not have a comprehensive curriculum even now! Role of MD in care of dying not defined Societal attitudes: The “Culture of Medicine” (C. Cassell)

    9. Traditional Goals of the Medical Profession: To cure SOME To relieve OFTEN To comfort ALWAYS

    10. The “Culture” of Medicine Focus on “curing” Public expects miracles So does physician: death of patient viewed as a personal and / or professional failure by M.D. Perception of medical community: skills in palliative care are not highly valued

    11. “Just ‘cause the patient is dead is no reason to stop treating him” Graffiti on the wall of the staff toilet on Osler 2, Johns Hopkins Hospital, circa 1974

    12. “We must face the fact that we will eventually fail with all our patients” Quote from an attending physic-ian ADVOCATING improving terminal care standards

    13. Chemotherapy and radiation therapy have failed... What is the role of the physician now? “ We have nothing more to offer” ? ! Note: The physician’s statement “we have nothing more to offer” is both professionally and ethically wrong! Making this statement constitutes abandonment of the patient at a time of crucial need.Note: The physician’s statement “we have nothing more to offer” is both professionally and ethically wrong! Making this statement constitutes abandonment of the patient at a time of crucial need.

    14. Palliative Care: the treatment of symptoms or suffering caused by an illness without attempting to cure the underlying illness Usually done when curative therapy is not possible

    15. What the patient needs from the physician LEADERSHIP--someone to guide them through the process PRESENCE HONESTY INFORMATION

    16. What is the Physician’s role in palliative care Effective Communication... Timely discussion of disease process, prognosis, treatment Respect patient’s choices Compassion: Empathy for patient and family

    17. Physician’s Role in Palliative Care (cont’d) Prognostication Symptom Management Continual presence

    18. Physician’s role in palliative care (cont’d) Understand the legal and ethical issues

    19. Hospice Care A shift in focus of treatment to intensive palliative care symptom management allows patient to live life to fullest addresses emotional / spiritual issues of terminal illness Interdisciplinary team approach Not a place: hospice is where the patient is

    20. What to tell your patients about hospice As your physician, I will continue to see you and to care for you-- Our first priority is managing your symptoms Services are available at home Your family will also receive the support of the hospice team Hospice care is covered by medicare, medicaid and many private insurers...

    21. The Interdisciplinary Team the patient and family the DOC You The Medical Director Nurse Home health aide Chaplain/spiritual advisor Social Worker Volunteer Pharmacist Physiotherapist, occupational, speech, music/arts therapists Dietician Janitor....

    22. How can we make things better? Understand that Palliative treatment that allows a dignified and gentle death of a terminally ill patient is a medical accomplishment of considerable merit, not a “failure”

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