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Tuesday, September 4, 2012

Why Doctors May Not Discuss Palliative/Hospice Care

There are a number of reasons your doctor or the doctor of your loved one may not recommend palliative or hospice care. Here are some common reasons:
  • She may believe palliative care is only appropriate when no other medical options are available.
  • He may over-estimate your life expectancy
  • She may feel she is letting you down or depriving you of hope
  • He may simply feel uncomfortable discussing the issue
  • She may have personal cultural/religious beliefs which bias against such recommendations
Let's look at these biases:

Unlike the old view that hospice care is like a line in the sand between living and dying, palliative care today may be provided concurrent with curative treatment.  The NY Times reports,

"In a study that sheds new light on the effects of end-of-life care, doctors have found that patients with terminal lung cancer who began receiving palliative care immediately upon diagnosis not only were happier, more mobile and in less pain as the end neared — but they also lived nearly three months longer."

Doctors over estimate life expectancy by as much as 30%.  This may lead to delayed discussion as your doctor believes there is time to have this discussion later.

It's bad enough that your doctor may be the bearer of bad news when giving you your diagnosis.  The prospect of also stripping you of hope is a potent influence on the willingness to discuss your wishes as medical therapy loses benefit.  However, hope for cure can become hope for being pain free, hope for remaining functional, independent and alert, and hope for a comfortable death.

It's tough to know what to say and how to say it. I had a patient who transferred care from my partner to myself. She characterized my partner as being a "marshmallow".  In his defense, he is a warm, kind-hearted and sensitive man.  She valued, however, a more direct approach.  She wanted diagnosis, prognosis and prioritized treatment plans in a matter of fact delivery without the touchy-feely, which I was able to provide.  In my defense, I can also be a marshmallow.

Cultural and religious beliefs influence us all.  Your doctor may have such beliefs which makes her more or less inclined to discuss palliative care.  It is acceptable to ask, "Do you have personal views which may make you reluctant to discuss all options for my care?"

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