146. Hanging on for Dear Life

In his third Reith Lecture Dr Atul Gawande, focuses on the approach by doctors to patients with diseases which may be terminal (1). One of the big changes that has occurred in the last 50 years or so has been the increase in the number of people who now die in hospital or other institutions, currently about 8 out of 10 deaths. Dr Gawande is especially concerned that the medical profession could do a lot better in the way it deals with these people. He describes how his daughter’s music teacher contracted cancer that was almost certainly terminal but that he felt incompetent to decide what was best for her. As a cancer surgeon, he could operate but while that might give her extra time it would also make her feel worse. On the other hand he was not comfortable about doing nothing.
So he talked to various people about the circumstances and asked them what was they thought best way forward. Here is what he discovered.
• There has been a failure to recognise that people have priorities other than the desire to live as long as possible and they would like to have support in meeting those priorities. These can include help to maintain their cognitive function, spending more time at home rather than in hospital or even just having the company of their dog.
• The most reliable way to learn what these priorities are is to ask the people themselves. As a general rule this just does not happen. In a study with cancer patients who were in a very advance stage – less than a third of them had had a conversation with their physician about their priorities and goals for their end of life. It was significant that this group did far better and had less suffering. They were more likely to get the care that they wanted, less likely to die in the hospital or ICU, and more likely to die at home or with family. Interestingly, 6 months after their death their family members were less likely to be depressed or to have post-traumatic stress disorder symptoms. In a study conducted at Massachusetts General Hospital patients with Stage IV lung cancer were divided into 2 equal groups. One got the usual oncology care but the other also had the usual care plus access to a palliative care physician who would discuss with them what their priorities and goals might be for the end of life. The group who had that discussion ended up choosing to stop chemotherapy sooner. They were much less likely to go onto the fourth round of chemotherapy, which meant that there was a saving of about one third in the chemotherapy costs. Their time in hospital was also reduced by a third. They were much less likely to die in the hospital and they moved to a hospice earlier. Essentially they had a better quality of life than those who were not given the opportunity to discuss their circumstances and effectively have a say in how they treated as the end of their lives approached. To cap it all, they actually survived for about 25% longer than those in the other group.
• Doctors have a tendency to blind patients with information but Dr Gawande discovered that this is not very helpful. On the other hand, if people are given the opportunity to express themselves, they are much more likely to come to terms with their worries and anxieties. He realised that he had been doing far too much talking, up to 90 % of the time. People told him that he should not be talking for more than 50% of the time in order to allow the patients to ask questions and explain their preferences and concerns.
Instead of bombarding patients with facts and figures, the physician should concentrate on encouraging them to be forthcoming and one way to do this is by asking a number of questions.
The scenario painted here is probably familiar to many. A person who has just been diagnosed with a terminal illness is probably shell-shocked and therefore not in a fit state to have any kind of rational discussion. Even after some time, the tendency will be to rely on the physician to spell out the options and the prognoses. The work of Dr Gawande described here and in the previous blog (2) confirms that there is excessive use of many treatments and procedures. The study at Massachusetts General Hospital has produced some fascinating results with less treatment resulting in improved quality of life and a greater life expectancy not to mention the cost saving due to the reduction in treatments. With respect to cancer, we are left without the answer as yet to the intriguing question “Would the patients have done even better without any conventional radiotherapy and chemotherapy?”
Dr Gawande has made no attempt to deal with the fundamental causes of cancer although it is relatively uncommon for this issue to be raised in conventional medicine. However the reality is that even if a tumour is removed the chances of a recurrence must be very high if the lifestyle remains unchanged. It has been established that diet (or rather a poor diet) is one of the major factors which contributes to the development of various cancers. The work of the Otto Warburg showed that in cancer cells energy is utilised by means of fermentation so that glucose is the prime source. On the other hand, unlike healthy cells, the cancer cells cannot utilise fat. Hence with a diet which is low in sugar and carbohydrates generally, the growth of the cancer cells is retarded and may even cease completely. Furthermore there are many foods which can boost the immune system and therefore improve the ability of the body to repair itself. Dr Gawande would be doing us all a great service if he was to turn his attention to the potential of dietary changes to overcome some of our common chronic diseases. Obviously he has the ability to reach out beyond conventional thinking. Even more important he has established a unique international reputation so there is every possibility that when he speaks people in high places will listen.
1. http://downloads.bbc.co.uk/radio4/open-book/2014_reith_lecture3_edinburgh.pdf
2. https://vernerwheelock.com/?p=672

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