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Care at the end of life is just good medicine

If you are in Rome and have only one day, you can cram in visits to as many monuments as possible, finding yourself at the train station with blurred and transient memories. Or you can climb the Gianicolo Hill, survey a panoramic vision of the city and decide which monuments really matter most to you.

The latter will grant you perspective and a visit that will be meaningful and lasting. Imagine your incoming death as your personal Gianicolo Hill, the opportunity to revisit the whole of your life and to distill from it what you consider your own imperishable monuments.

You will then leave to your children and grandchildren a precious perfume that will remain alive many years after your death.

I gave this talk to an elderly woman, whose liver cancer had progressed despite all treatment. She, her husband and each of her five children hugged me before moving toward the exit. I may never see any one of them again, but something we shared remains and abides in me. There had been a spiritual exchange.

If you have deep faith or none at all, accompanying a patient to the threshold of death involves both a contact with the human mystery and a personal exchange that allows people to survive through each other. The lady died three days later. The night before her death, she enjoyed a gulp of her favorite bourbon — a pleasure she had religiously avoided to avoid worsening her liver failure.

This type of conversation takes place at least twice a week in my office. Sometimes, when addressing death, I've included the input of an allied professional — a psychologist, clinical social worker or chaplain. Though it is the most rewarding experience of my profession as an oncologist, it is also very time consuming and emotionally draining. The conversation is not always smooth.

I recall a man who left the room, refusing my hand and slamming the door after I told him that I had no more treatments to offer. A colleague reported a woman who became completely withdrawn from her family as she approached death. After long and painful probing she admitted she feared for her soul; she worried she would be damned for an abortion three decades before. That conviction led her to believe she would not see her children in the next life and to the decision, therefore, to take a leave from them during the last days of this life.

These situations are spiritual emergencies. They cause intense terminal anguish and suffering and can only be addressed with time and sensitivity. I am allowed plenty of time to communicate with my patients because my institution believes in the value of compassion. But I don't know how many of my colleagues who are mandated to see a patient every 10 minutes to meet budgetary demands can find the time for this type of advice and assistance. In recognizing the problem, the Obama administration has recommended that physicians be paid for end-of-life counseling.

The benefit cannot be overemphasized. It allows the patient to exercise autonomy, a medical ethic only possible through informed consent and the disclosure of clear and proper information. Death is unavoidable. And it is the patients' right to know, to our best approximation, how and when they are going to die. End-of-life discussion brings back to medicine the element of compassion and spiritual care that used to be one of the hallmarks of the profession, as envisioned by Hippocrates.

The Republican-majority U.S. House wants to repeal health care reform, and some of its leaders, echoing Sarah Palin, have used the phrase "death panels" to refer to this compassionate approach to dying. Nothing could be further from the truth. Such blatant governmental interference in patient-physician interactions would rob medicine of compassion and of spirituality.

Death panels do indeed exist. Death-making policies exist when third-party payers refuse to insure patients with pre-existing conditions, increase insurance premiums to unaffordable rates when people develop chronic diseases, and minimize reimbursement for hospitalization. All of these do indeed manage to shorten the life of the most "expensive" clients. It is good for the profit margin. But it spells death for the vulnerable.

Dr. Lodovico Balducci is a professor of oncology and medicine at the University of South Florida College of Medicine and is director of the Division of Geriatric Oncology at the H. Lee Moffitt Cancer Center.

Care at the end of life is just good medicine 01/30/11 [Last modified: Sunday, January 30, 2011 6:38pm]
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