LMS President’s Message, November 2018
Tuyen T. Tran, MD, MBA
One of the unforeseen challenges resulting from the technological advances in medicine is the blurring of death and dying. As physicians and community leaders, we need to carefully think about our role in providing care to patients at the end of life. What are our professional duties to the patients and their families? How do we determine when to stop pursuing cure instead of care when advanced technology may offer opportunities to ward off the inevitable, albeit brief? We listen to the patient.
We should all take pride in our contribution to many of the successful accomplishments of modern medicine. Our campaign to combat death has been very successful. In the past century, life expectancy has increased by about 30 years. Per CDC statistics, Men and women born in 1900 had a life expectancy of 48 and 51, respectively; but, by 2000, the life expectancy jumped to 74 for men and 79 for women. In 1900, infectious diseases (influenza, pneumonia, tuberculosis, and GI infections) were the leading causes; but, today, these illnesses are no longer leading causes. Instead, chronic conditions such as heart disease, cancer, chronic lower respiratory diseases, strokes, and diabetes have assumed the top causes of death. People are living longer and will naturally accumulate more chronic illnesses. Our unrelenting pursuit of medical progress has enabled us to keep very sick people alive much longer. Although, there is always some technological option to offer a dying person a few more hours, days, weeks, or even months, how do physicians know when to transition from cure to care mode?
The value of engendering hope to dying patients and their families is immeasurable. Very few of us want to die. And very few people want to lose their loved ones. If there is an option to prolong the patient’s life for a few more hours, days, weeks or months, who should decide whether it is worth pursuing? Should patients decide? What if the decision is contradictory to the patient’s living will? Does it matter that a dying person’s decision might be biased or coerced because of his/her plight? Should families decide? What role should the doctor play in these scenarios? How can doctors prevent imposition of his/her will upon the patients? Is it wrong for the doctor to fight as the patient’s champion against death? How does a doctor know when to transition from cure to care? At what cost (not necessarily financial) is patient and/or family and doctor willing to pay? Does society and governmental agencies have a voice?
While everyone of these stakeholders influence the patient’s decision, most of us agree that the patient’s decision is paramount. But how will we know if the patient had sufficient information and understanding of the situation and/or options? We need to learn to listen to our patients. In 2001, the Institute of Medicine (IOM) established patient-centered care as one of its six aims for the health care system. Partnering with patients/families provides guidance for doctors to deliver excellent quality of care, not just attempts to cure.
Everyone has experienced death (usually in old age) of a spouse, parent, or grandparent and sometimes tragically, a younger person whose time of death arrived prematurely. Was the death peaceful? When my time comes, what and how do I want my death to proceed? Hopefully, my doctor is listening.