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Changing Costs And Care At The End Of Life

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Julie Goldstein, M.D., Martha Twaddle, M.D., Mary F. Mulcahy, M.D., Randi Belisomo, M.S.J.

Palliative care is an expanding and increasingly vital specialty of medicine, said end of life care expert Martha Twaddle, M.D., at a presentation for the Association of Health Care Journalists- Chicago Chapter.

“When I joined the American Academy of Hospice and Palliative Medicine, there were 50 of us– 25 were from Australia and the UK. Now, the membership is well into the thousands,” said Twaddle during the presentation, “Changing Costs and Care at the End of Life,” which included Life Matters Media co-founders, Randi Belisomo and Mary F. Mulcahy, M.D., and Advocate Illinois Masonic palliative care physician Julie Goldstein, M.D.

The presentation sought to explore end of life options in light of the “death panels” controversy, one which effectively eliminated efforts to compensate physicians for facilitating end of life discussions with patients.

Physicians typically only spend fifteen to twenty minutes with each patient. “It’s not a lot of time,” Mulcahy said. “You cannot go into these discussions with an agenda, you really have to speak with the family, the patient.”

In a complex field such as oncology, physicians must not only address disease treatment, but symptom management as a result of  that treatment as well. In the course of a twenty minute appointment, treatment and symptoms are often too much to cover effectively; therefore, a robust discussion surrounding end of life issues is often not possible, Mulcahy said. These discussions, because their relevance may seem “far off” for patients, are frequently given low-priority by physicians and thus delayed.

Palliative medicine and hospice care allows patients more comfort at the end of life by reducing aggressive treatments and emphasizing pain management. Still, most patients remain skeptical or unaware of such treatments. Some physicians do not mention such care out of fear of being accused of “giving up” on their patients. Others simply avoid comprehensive end of life conversations altogether.

“When I sit down with patients and they say, ‘What’s palliative medicine?’ It’s easy to contrast it to what it isn’t, i.e. current medical care,” Twaddle said. “Current medical care is based on a biomedical model: here is the diagnosis, here is the treatment.”

However, palliative care is based off the roots of medicine, Twaddle explained, a biomedical-psycho-social-spiritual model. This “allopathic model” aims to cure the whole person, both body and soul- not just the disease. This model has been lost since the time of Descartes and the onset of modern technologies, she said.

“Palliative medicine’s secret agenda is to restore the wholeness of medicine, to bring it back to the person,” Twaddle said. Instead of beginning a doctor-patient dialogue with a discussion about treatment, care starts with a physician asking questions about the patients’ beliefs, ideals and wishes- what Twaddle called “the art of communication in medicine.”

Recently, Frederick Smith, M.D., director of clinical ethics at North Shore-LIJ Health System, said physicians have an ethical duty to inform their patients facing the end of life about hospice and palliative care services.

Smith’s presentation, part of the University of Chicago’s second annual Conference on Medicine and Religion, criticized the choices of many physicians who urge their patients to continue with more aggressive, painful treatments instead of more comfortable end of life care.