Being Mortal: Frontline Explores Death And Dying

Being Mortal: Frontline Explores Death And Dying

Posted on Wednesday, February 11th, 2015 at 3:47 pm by lifemediamatters

FRONTLINEPBS Frontline brought frank discussion about death and dying to American homes Tuesday night with “Being Mortal,” a passionate documentary based on Dr. Atul Gawande’s bestselling book of the same name.

Americans face many challenges in initiating end of life care conversations, said Gawande, a general surgeon at Brigham and Women’s Hospital and the Dana-Farber Cancer Institute. Seriously ill patients often focus on “how to beat the steep odds against them” without hearing from doctors and caregivers about how certain aggressive treatments may worsen their final days and hours.

Instead of dying at home with supportive comfort care, as the vast majority of Americans wish, many end up in hospitals surrounded by emotional family members who disagree about their final wishes.

“All of the stuff you learned about in medical school is just a tiny little bit of what it means to be good at our jobs,” Gawande offered. “So many people have their death come as a total surprise.”

Most of the documentary centered on the reluctance of many surgeons and oncologists to engage dying patients in meaningful discussion about prognosis and care options.

“It’s always a challenge how to say it, that this is not working and I have nothing more,” said Dr. Lakshmi Nayak, a neuro-oncologist at Dana-Farber. “I have tried to deliver the information in pieces over a period of time.”

In one emotional scene, Nayak has difficulty explaining to a patient and his wife why she has no further curative therapy to offer for his aggressive brain tumor.

It may be up to the patient to ensure that his or her end of life wishes are honored, because physicians often will not, Gawande cautions.

Dr. Monica Williams-Murphy, an award-winning writer and emergency physician at Huntsville Hospital in Alabama, called the documentary a “great introduction to how Americans may face death.” However, she would have liked it to explore diseases beyond cancer.

“As an emergency physician, I see death that is both expected and unexpected. We have all got to manage the many forms of being mortal better,” she told Life Matters Media. “Additionally, there was no mention of advanced directives, something that everyone over 50 absolutely should have. Conversations upstream in health care may ease the medical moments portrayed in the film.”

An advance directive may take the form of a living will, power of attorney for health care or do-not-resuscitate order. The purpose of such forms is to help ensure one’s end of life wishes are honored in case of illness or incapacity. Nationally, only 30 percent of adults die with advance directives.

Dr. Karen Wyatt, a family practice physician and end of life care advocate, said she would have liked the documentary to have explored benefits of earlier hospice enrollment. Hospice care is designed to help comfort terminally ill patients in their last months of life. The goal is not cure, but symptom management.

“The film barely touched the surface of what we need to talk about, but it was a great introduction to end of life issues. An appetizer,” she told LMM. “If a hospice physician would have created the film, it would have been entirely different. Those of us who care for dying patients in their home see an entirely different end of life experience.”

Wyatt said she believes some physicians will be inspired to start talking about death and dying with their terminally ill patients earlier.

“Gawande comes from within the hallowed halls of Western medicine and speaks directly to his colleagues,” she added. “He has credibility.”

Viewers were encouraged to tweet their reactions and share what matters most to them during the hour-long program (#WhatMattersMost and #BeingMortal quickly became trending topics, after thousands of messages were sent).


Spirituality At End Of Life

Posted on Friday, December 28th, 2012 at 5:07 pm by Life Matters Media

Spirituality

Physicians and nurses at Boston medical centers cited a lack of training as the main reason why they rarely provided spiritual care for their terminally ill cancer patients, even though most patients considered it important to their end of life care.

A new study published in the Journal of Clinical Oncology reports that out of the 204 physicians from four medical centers who participated in the three year study, just 24 percent reported providing spiritual care. Among the 118 nurses, only 31 percent reported providing care.

“I was quite surprised that it was really just lack of training that dominated the reasons why,” senior author Dr. Tracy Balboni, an oncologist at the Dana-Farber Cancer Institute in Boston and researcher of spirituality, told Reuters Health.

Spiritual care may range from prayer with a physician or nurse to recommendations for a hospital chaplain.

Spiritual care “is considered by patients to be an important aspect of end of life care and is also associated with key patient outcomes, including patient quality of life, satisfaction with hospital care, increased hospice use, decreased aggressive medical interventions, and medical costs,” Balboni said.

Even though current palliative care guidelines encourage medical practitioners to mind religious and spiritual needs that arise during a patient’s end of life care, most medical practitioners remain silent. Ninety-four percent of patients with advanced cancer had never received any form of spiritual care from physicians.

Stanford School of Medicine

Stanford School of Medicine

Spiritual care may become more common in the future, however. “There was a time when nurses and physicians may have said, ‘That’s not my job,’ but I think the tides are changing,” said palliative care researcher Betty Ferrell of City of Hope, a cancer research center in Duarte, California.

“I think we are realizing we can no longer ignore this aspect of care,” Ferrell told Reuters. She’s a professor of nursing who was not involved in the new study.

Study researchers suggest more spiritual care training for physicians and nurses. The study found only 13 percent of doctors and nurses reported having such training. However, those who received training were almost 11 times more likely to provide spiritual care to their patients than those who had not.


Terminally Ill Opt For Less Treatment When In Communication With Doctors

Posted on Tuesday, November 27th, 2012 at 1:43 pm by Life Matters Media

Cancer patients who talk with their physicians about how they want to die are less likely to opt for aggressive end of life treatments in the last two weeks of life, according to a new study published in the Journal of Clinical Oncology. Instead, these patients end life more comfortably at home or in hospice care, and as a result spend much less on hospital care.

“Aggressive care at the end of life for individual patients isn’t necessarily bad, it’s just that most patients who recognize they’re dying don’t want to receive that kind of care,” said Dr. Jennifer Mack, lead author of “Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study.”

“We should at least consider having these discussions soon after diagnosis if we know that a patient has incurable cancer,” Mack, from the Dana-Farber Cancer Institute in Boston, told Reuters Health.

The researchers studied more than 1,200 patients with stage IV lung or colorectal cancer who survived at least one month from the time of diagnosis, but died during the 15-month study period. Using interviews of the patients and/or their caregivers and a comprehensive medical record review, the researchers determined if and when the patients had discussions with their doctors about end of life.

Researchers found that 88 percent had end of life discussions, but more than one-third of those took place less than a month before the patient died. Those patients who had end of life discussions documented in the medical record but did not recall them in the patient or surrogate interviews were more likely to have chemotherapy within the last 14 days of life, or acute intensive or hospital care within the last 30 days of life.

Patients who reported having the discussions with doctors were almost seven times more likely to end up in hospice than those who didn’t have those talks. Hospice focuses on comfort care and pain management for terminal patients, instead of treatment.

“A lot of patients don’t want (aggressive treatment), but they don’t recognize that they’re dying or that this is relevant for them,” said Dr. Camilla Zimmermann, head of the palliative care program at University Health Network in Toronto. She wasn’t involved in the study.

She told Reuters: “The earlier you discuss these things, the more options you have. If you wait too long, you end up having these discussions with someone you don’t know, that you just met, in an inpatient setting,” instead of with your primary doctor.

According to Mack, “If we start these conversations early, then patients have some time to process this information, to think about what’s important to them (and) to talk with their families about that.”

In 2010, Medicare paid $55 billion for doctor and hospital bills during the last two months of patients’ lives- more than the budget for the Department of Homeland Security, according to CBS News. Twenty to 30 percent of those medical expenses may have had no meaningful impact on the patients’ health.

Reuters is reporting data from the Dartmouth Atlas of Health Care, which found that 32 percent of total Medicare spending goes to caring for sick patients in their last two years of life.

National guidelines recommend patient-physician talks begin soon after a terminal cancer diagnosis. Researchers found that physicians initiated end of life discussions an average 33 days before death.