Friday, July 21, 2006

The Shift from Cure to Care

End-of-life issues. Ethicists, scholars, and doctors struggle with these every day in our healthcare arena.

Yesterday the New York Times let us see the face of Dr. Anna M. Pou who is accused of using lethal injections to kill several patients who were in extreme distress after Hurricane Katrina. She's a real person, who made some real, difficult, and human decisions. The circumstances are unclear but the situation was clearly difficult. Were her actions sinister or benevolent? And while the courts will be asked to decide this case, realize that these tough life-and-death decisions occur every day in our hospitals.

An example: recently doctors were asked to place a pacemaker in a 99-year old man who had just suffered a large heart attack several days earlier and was not felt to be a candidate for open heart surgery due to his other medical conditions (he was "too old"). His heart rate limited the number of heart medications he could take for his pain. He had some blood in his stool when previously anticoagulated, so angioplasty was not an option. In the interest of supporting his heart rate safely while receiving more heart-related medications, a pacemaker was recommended.

But was he also "too old" for a pacemaker? Is there an upper limit to the age a patient should receive such a device? How much money should be spent in end-of-life healthcare? With the ever-rising cost of healthcare today, is there a place for such a discussion? What assurance is there that the pacemaker will be effective or that the patient will not suffer a complication of the implant procedure? What are the implications for withholding pacemaker therapy? Would pain medications like morphine, with its known analgesic effects, be more immediately therapeutic for the patient? Or would morphine's use expose these doctors to litigation, like Dr. Pou?

Decisions like these are never easy. Sometimes, our toughest decisions in medicine occur when we stop trying to cure our patients and instead decide to continue caring for them.

And we must not lose sight that we are involved in healthcare, not healthcure.


1 comment:

Anonymous said...

I am also a physician, and I would argue that we are not involved in healthcare. I would describe the majority of our training and our workday as being spent on what would better be described as diseasecare. Think back to med school, internship,(Did you know intern means to be held against ones will?) residency, fellowship and beyond Dr. Wes. How many hours did you spend in formal training about indicators of health such as nutrition, quality of sleep, or VO2 max? How much time was spent on death as a natural part of life? Now,how much time on pathology, natural history of disease and treatment?