IDEAS AND OPINIONS
IMPROVING PATIENT CARE
The Doctor: For Life and at the End of Life Philip A. Pizzo, MD
A
lthough it is easy to look on Sir Luke Fildes' 1887 portrait The Doctor (Figure) with a nostalgic nod to a past era, this painting still portrays, with sensitive clarity, the deep feelings of compassion, care, and concern that many of us aspire to emulate in medicine. I have viewed this painting through different lenses over my career: as a pediatric oncologist who deeply felt the loss of each patient and saw the piercing impact on the surviving family; as a physician–scientist who strove to discover and develop new treatments for catastrophic diseases in children and pushed the edges of medical therapy; and as an administrative leader of academic medical centers who witnessed the increasing complexity of medicine, with more compartmentalization, fractured delivery of care, rising costs, and growing demands that sapped time and sometimes compassion. In each of these settings, one might yearn—as a patient, family member, or physician—for a simpler, less technologically driven time when listening to, touching, and caring for patients and their families were the most important values in medicine. This is especially true for adults and children who face serious advanced disease and are nearing the end of life. Unfortunately, as a nation, we do a disappointingly poor job of delivering seamless, compassionate care that honors the individual preferences of those nearing the end of life. This happens mainly because we do not know or uphold what our patients want or desire and neglect to listen or take the time to convey information completely and accurately. The recent report from the Institute of Medicine titled “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life” by the Committee on Approaching Death, which I co-chaired with former U.S. Comptroller General David Walker and 19 other experts from diverse backgrounds, poignantly delineates this dilemma (1). Among our report's major contributions was offering a model of care that, in some ways, is consonant with the compassion depicted in Fildes' painting more than a century ago. Specifically, we recommended that care for those with advanced serious illness should be seamless, highquality, integrated, patient- and family-centric, and consistently available. This care should consider the evolving physical, emotional, social, and spiritual needs of patients and caregivers and should be delivered by persons with appropriate training and expertise. Of
See also: Related articles . . . . . . . . . . . . . . . 175, 224, 226, 230 Celebrating the ACP Centennial: From the Annals Archive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 This article was published online first at www.annals.org on 9 December 2014. 228 © 2015 American College of Physicians
Figure. Sir Luke Fildes' 1887 portrait The Doctor.
particular importance, we recommended that “all people with advanced serious illness should have access to skilled palliative care, or, when appropriate, hospice care in all settings where they receive care (including health care facilities, the home, and the community).” Moreover, we recommended that “palliative care should encompass access to an interdisciplinary palliative care team, including hospice and palliative care medicine physicians, nurses, social workers, and chaplains, together with other professionals as needed” (1). How does this differ from what happens now? In the case of a patient with cancer, what the oncologist conveys about the potential benefits of treatment can be strikingly incongruent with what the patient understands, desires, or experiences. For example, a reported 69% of patients with advanced lung or colorectal cancer did not understand that their condition was incurable (2). Although oncologists often disclose that treatment is likely noncurative, they rarely check the patient's understanding of their communication. In addition, they present alternatives to aggressive medical therapy in fewer than half of their encounters. Not surprisingly, although the Institute of Medicine Committee on Improving the Quality of Cancer Care recently underscored the importance of being attentive to patients' end-of-life preferences, it noted that physicians inquire about these preferences less than half of the time (3). Understandably, many oncologists are concerned about depriving the patient of hope or are worried about incurring the family's blame for not conveying an optimistic attitude or treatment plan. Unfortunately, this means that oncologists can use ambiguously optimistic language and may not take the time to listen to or fully
IDEAS AND OPINIONS
The Doctor
appreciate their patient's desires or preferences, including views about intensive care treatment or cardiopulmonary resuscitation. Of note, discussions by the oncologist about palliative care, hospice, or other alternatives do not increase depression in patients. In fact, the early introduction of palliative care can ensure greater comfort during cancer treatment and at the end of life and can lead to an improved quality of life and greater longevity when provided in tandem with disease-focused therapy (4). These and related studies have led the American Society of Clinical Oncology to recommend that palliative care be combined with standard oncology care early in the course of illness for patients with metastatic disease or a high burden of symptoms (5). There is no need for a dipole between cancer treatment and palliative care, including conversations about end-of-life care. This raises another important question: What is the role of the oncologist and palliative care specialist during the course of illness and at the end of life? Over the past decade, palliative care has emerged as a new professional specialty that includes board-certified physicians and nurses as well as social workers, clergy, and other professionals. Currently, more than 85% of hospitals with more than 300 beds have a palliative care program. But palliative care must extend beyond the hospital into the ambulatory, community, and home settings to optimize its effect. And the boundaries between palliative care and hospice care need further integration, especially for patients nearing the end of life. Although the oncologist who maintains the role of the “treating” physician working in tandem with a palliative care specialist is a model that can work, I worry about oncologists who hand off their patients and their families to other providers— even well-trained and prepared palliative care specialists—at a critical phase. As a pediatric oncologist, I have viewed my role as staying with patients and their families throughout the illness and potentially through death. This requires oncologists to acquire skills in “basic” palliative care that can be complemented by specialists in palliative care medicine, but that allows them to be part of a team, not simply
www.annals.org
one face of the life– death dyad. Finding this zone of equipoise, the very angle of repose for each patient and family, can better allow the physician to emulate the compassion captured by Fildes in The Doctor and thus benefit the patient in life and at death. From Stanford University School of Medicine, Stanford, California. Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje /ConflictOfInterestForms.do?msNum=M14-2399. Requests for Single Reprints: Philip A. Pizzo, MD, Stanford University School of Medicine, Lorry Lokey Research Building, 265 Campus Drive G1078, Stanford, CA 94305; e-mail, ppizzo @stanford.edu.
Author contributions are available at www.annals.org. Ann Intern Med. 2015;162:228-229. doi:10.7326/M14-2399
References 1. Committee on Approaching Death; Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Pr; 2014. 2. Weeks JC, Catalano PJ, Cronin A, Finkelman MD, Mack JW, Keating NL, et al. Patients' expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-25. [PMID: 23094723] doi:10.1056/NEJMoa1204410 3. Committee on Improving the Quality of Cancer Care; Institute of Medicine. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: National Academies Pr; 2013. 4. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non– small-cell lung cancer. N Engl J Med. 2010;363:733-42. [PMID: 20818875] doi:10.1056/NEJMoa1000678 5. Smith TJ, Temin S, Alesi ER, Abernethy AP, Balboni TA, Basch EM, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2012;30:880-7. [PMID: 22312101] doi:10.1200/JCO .2011.38.5161
Annals of Internal Medicine • Vol. 162 No. 3 • 3 February 2015 229
IMPROVING PATIENT CARE Author Contributions: Conception and design: P.A. Pizzo.
Analysis and interpretation of the data: P.A. Pizzo. Drafting of the article: P.A. Pizzo. Critical revision of the article for important intellectual content: P.A. Pizzo. Final approval of the article: P.A. Pizzo. Collection and assembly of data: P.A. Pizzo.
www.annals.org
Annals of Internal Medicine • Vol. 162 No. 3 • 3 February 2015
Copyright © American College of Physicians 2015.
IMPROVING PATIENT CARE
The Doctor: For Life and at the End of Life Philip A. Pizzo, MD
A
lthough it is easy to look on Sir Luke Fildes' 1887 portrait The Doctor (Figure) with a nostalgic nod to a past era, this painting still portrays, with sensitive clarity, the deep feelings of compassion, care, and concern that many of us aspire to emulate in medicine. I have viewed this painting through different lenses over my career: as a pediatric oncologist who deeply felt the loss of each patient and saw the piercing impact on the surviving family; as a physician–scientist who strove to discover and develop new treatments for catastrophic diseases in children and pushed the edges of medical therapy; and as an administrative leader of academic medical centers who witnessed the increasing complexity of medicine, with more compartmentalization, fractured delivery of care, rising costs, and growing demands that sapped time and sometimes compassion. In each of these settings, one might yearn—as a patient, family member, or physician—for a simpler, less technologically driven time when listening to, touching, and caring for patients and their families were the most important values in medicine. This is especially true for adults and children who face serious advanced disease and are nearing the end of life. Unfortunately, as a nation, we do a disappointingly poor job of delivering seamless, compassionate care that honors the individual preferences of those nearing the end of life. This happens mainly because we do not know or uphold what our patients want or desire and neglect to listen or take the time to convey information completely and accurately. The recent report from the Institute of Medicine titled “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life” by the Committee on Approaching Death, which I co-chaired with former U.S. Comptroller General David Walker and 19 other experts from diverse backgrounds, poignantly delineates this dilemma (1). Among our report's major contributions was offering a model of care that, in some ways, is consonant with the compassion depicted in Fildes' painting more than a century ago. Specifically, we recommended that care for those with advanced serious illness should be seamless, highquality, integrated, patient- and family-centric, and consistently available. This care should consider the evolving physical, emotional, social, and spiritual needs of patients and caregivers and should be delivered by persons with appropriate training and expertise. Of
See also: Related articles . . . . . . . . . . . . . . . 175, 224, 226, 230 Celebrating the ACP Centennial: From the Annals Archive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 This article was published online first at www.annals.org on 9 December 2014. 228 © 2015 American College of Physicians
Figure. Sir Luke Fildes' 1887 portrait The Doctor.
particular importance, we recommended that “all people with advanced serious illness should have access to skilled palliative care, or, when appropriate, hospice care in all settings where they receive care (including health care facilities, the home, and the community).” Moreover, we recommended that “palliative care should encompass access to an interdisciplinary palliative care team, including hospice and palliative care medicine physicians, nurses, social workers, and chaplains, together with other professionals as needed” (1). How does this differ from what happens now? In the case of a patient with cancer, what the oncologist conveys about the potential benefits of treatment can be strikingly incongruent with what the patient understands, desires, or experiences. For example, a reported 69% of patients with advanced lung or colorectal cancer did not understand that their condition was incurable (2). Although oncologists often disclose that treatment is likely noncurative, they rarely check the patient's understanding of their communication. In addition, they present alternatives to aggressive medical therapy in fewer than half of their encounters. Not surprisingly, although the Institute of Medicine Committee on Improving the Quality of Cancer Care recently underscored the importance of being attentive to patients' end-of-life preferences, it noted that physicians inquire about these preferences less than half of the time (3). Understandably, many oncologists are concerned about depriving the patient of hope or are worried about incurring the family's blame for not conveying an optimistic attitude or treatment plan. Unfortunately, this means that oncologists can use ambiguously optimistic language and may not take the time to listen to or fully
IDEAS AND OPINIONS
The Doctor
appreciate their patient's desires or preferences, including views about intensive care treatment or cardiopulmonary resuscitation. Of note, discussions by the oncologist about palliative care, hospice, or other alternatives do not increase depression in patients. In fact, the early introduction of palliative care can ensure greater comfort during cancer treatment and at the end of life and can lead to an improved quality of life and greater longevity when provided in tandem with disease-focused therapy (4). These and related studies have led the American Society of Clinical Oncology to recommend that palliative care be combined with standard oncology care early in the course of illness for patients with metastatic disease or a high burden of symptoms (5). There is no need for a dipole between cancer treatment and palliative care, including conversations about end-of-life care. This raises another important question: What is the role of the oncologist and palliative care specialist during the course of illness and at the end of life? Over the past decade, palliative care has emerged as a new professional specialty that includes board-certified physicians and nurses as well as social workers, clergy, and other professionals. Currently, more than 85% of hospitals with more than 300 beds have a palliative care program. But palliative care must extend beyond the hospital into the ambulatory, community, and home settings to optimize its effect. And the boundaries between palliative care and hospice care need further integration, especially for patients nearing the end of life. Although the oncologist who maintains the role of the “treating” physician working in tandem with a palliative care specialist is a model that can work, I worry about oncologists who hand off their patients and their families to other providers— even well-trained and prepared palliative care specialists—at a critical phase. As a pediatric oncologist, I have viewed my role as staying with patients and their families throughout the illness and potentially through death. This requires oncologists to acquire skills in “basic” palliative care that can be complemented by specialists in palliative care medicine, but that allows them to be part of a team, not simply
www.annals.org
one face of the life– death dyad. Finding this zone of equipoise, the very angle of repose for each patient and family, can better allow the physician to emulate the compassion captured by Fildes in The Doctor and thus benefit the patient in life and at death. From Stanford University School of Medicine, Stanford, California. Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje /ConflictOfInterestForms.do?msNum=M14-2399. Requests for Single Reprints: Philip A. Pizzo, MD, Stanford University School of Medicine, Lorry Lokey Research Building, 265 Campus Drive G1078, Stanford, CA 94305; e-mail, ppizzo @stanford.edu.
Author contributions are available at www.annals.org. Ann Intern Med. 2015;162:228-229. doi:10.7326/M14-2399
References 1. Committee on Approaching Death; Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Pr; 2014. 2. Weeks JC, Catalano PJ, Cronin A, Finkelman MD, Mack JW, Keating NL, et al. Patients' expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-25. [PMID: 23094723] doi:10.1056/NEJMoa1204410 3. Committee on Improving the Quality of Cancer Care; Institute of Medicine. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: National Academies Pr; 2013. 4. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non– small-cell lung cancer. N Engl J Med. 2010;363:733-42. [PMID: 20818875] doi:10.1056/NEJMoa1000678 5. Smith TJ, Temin S, Alesi ER, Abernethy AP, Balboni TA, Basch EM, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2012;30:880-7. [PMID: 22312101] doi:10.1200/JCO .2011.38.5161
Annals of Internal Medicine • Vol. 162 No. 3 • 3 February 2015 229
IMPROVING PATIENT CARE Author Contributions: Conception and design: P.A. Pizzo.
Analysis and interpretation of the data: P.A. Pizzo. Drafting of the article: P.A. Pizzo. Critical revision of the article for important intellectual content: P.A. Pizzo. Final approval of the article: P.A. Pizzo. Collection and assembly of data: P.A. Pizzo.
www.annals.org
Annals of Internal Medicine • Vol. 162 No. 3 • 3 February 2015
Copyright © American College of Physicians 2015.
