Please, let us connect to our fellow patients!

Everyone concerned with improving health care should take a look at this article in the New York Times by Dr. David Stern. Its written by a cancer patient relating two experiences in what is obviously a high status hospital.

He wonders if he could have helped, or been helped by, his roommates, in both of whih cases had more advanced diagnosis than he. He did not even know their names, and heard their emotional and physical paid and felt unable to do anything.  In the econd case:

As with my last hospital roommate, I never saw this man’s face and we never spoke, but I feel immeasurably close to him, as though in some ways I know him better than my dearest friends. He heard me gasping for air through the night and yelping in pain as the chest tube got pulled, and I heard him trying to be brave for his family, reassuring them that they would go forward with whatever came next as best they could. I heard him speak in a reassuring voice to his children, only to hang up and weep loudly into the night until passing into a sleep from pure exhaustion.

Listening to him was like a kind of sonar, an echo bouncing back to me from my own future path, hinting at what’s to come.

When I was getting ready for discharge, I had the urge to pull the curtain and embrace him as he told me the secrets of what to expect next. I would ask how had he navigated the path from here to there. I would lay down the weight of uncertainty that surrounds my life and ask: What should I do now? How I can live with only a vague sense of dread of what’s to come as my guide?

But he could not have given me answers, just as no one could have articulated what lay ahead for me at other junctures, such as when I started medical school, became a husband and a father or at the time of my diagnosis. The next steps must be discovered in the journey itself.

Actually, maybe, no almost, certainly that patient could have given you something relevant and helpful, if not the final answer.  And, it would have helped my roommate to have helped me.  I certainly find that waiting room chats can be incredibly helpful to all of us.

I have to same, more importantly, that this article inspired in me no fear, notwithstanding a progressing terminal cancer.  This is simply because I have absolute faith that my doctors and other providers, my hospital, my palliate care program, and ultimately my hospice:

  • will let me make the connections I need to make,
  • keep me out of pain, unless I choose otherwise,
  • help me make human connections with those around me,
  • and will listen seriously to my suggestions for how to improve my experience and the system as a whole.

And, above all, I am certain, at least if I had asked, they would have obtained any HIPPA waiver they felt necessary, and introduced me and my roommate.  (Both my hospitalizations were in single rooms, as a general infection control measure.)

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Biometric Measures of Pain and Self Reporting of Side Effects

A few days ago, I blogged about the dificulty of self-reporting side effects.  The AP has just run a story on how it may be becoming possible to measure pain bio-metrically.

The National Institutes of Health is pushing for development of what its director, Dr. Francis Collins, has called a “pain-o-meter.” Spurred by the opioid crisis , the goal isn’t just to signal how much pain someone’s in. It’s also to determine what kind it is and what drug might be the most effective.

“We’re not creating a lie detector for pain,” stressed David Thomas of NIH’s National Institute on Drug Abuse, who oversees the research. “We do not want to lose the patient voice.”

Around the country, NIH-funded scientists have begun studies of brain scans, pupil reactions and other possible markers of pain in hopes of finally “seeing” the ouch so they can better treat it. It’s early-stage research, and it’s not clear how soon any of the attempts might pan out.

“There won’t be a single signature of pain,” Thomas predicted. “My vision is that someday we’ll pull these different metrics together for something of a fingerprint of pain.”

Obviously, there is still huge amounts to be leaned not only about the measures, but critically their relationship to how we as patients actually experience them.  I was very encouraged to see the quote from David Thomas “We’re not creating a lie detector for pain.  We do not want to lose the patient voice.

Obviously, this will require full involvement from patients in the research design, as well as making sure that those who are trained to use the new measures are fully informed of the relationship of patient experience to the numbers.  Its not hard getting researchers to understand, but less clear that harried caregivers will not be attracted to shortcuts.  In fact, quite apart from research into the reliability of the numbers, we will need research into what happens in the field –“first do no harm.”  I see this new ata ass potentially strengthening the patient partnerhsip, not weakening.

As some who has sat as a patient voice on numerous health care working groups, I have complete trust in the intent of the professional participants, but I have also seen how powerful that unified professional voice can be, unless we understand the full dynamics.

I hope that my caution does not undercut what I see as very good news here.

More on Identifying Side Effects

Yesterday, I blogged about how hard it can be for patients with co-morbidities to accurately report on side effects.Imuch appreciate the suggestions and ideas I got in response.

Here are some more ways to think about solving this problem:

Keeping a journal over time

Developing a neurological scan that shows nerve responses in real time

Developing brain scans and algorithms to identify side effect-related brain activity

Using medical staff with co-morbidities to do the side effects interviews

Asking families what patterns they are seeing

Including sensitivity to these issues in medical training and rounding

More suggestions and comments always welcome

 

On Identifying Side Effects for Patients with Co-Morbidities

As a patient with lots going wrong, I have found that when I try to answer a question about side effects from a new drug, I often get confused.  I think the reason is I already have so many of the side effects that appear on every drug list, that is it hard to calibrate an increase in side effects.

I suspect that treatment decisions have therefore been made for me based on what are really guesses on my part.  Its good to have my self-reporting taken seriously, but maybe I need some training on listening to my body better.

Remember that most providers are healthy, so that are not used to getting the constant alert messages that us perpetual patients are.  They have not developed the suppression and filtering tools that we have.

So, the question is what can we do?

Maybe patients should be trained in mindfulness on this.

Maybe we should test whether patients under hypnosis report more accurately on side effects.

Maybe providers should talk about this, and develop training protocols.

Maybe our research protocols should be improved to be sensitive to these issues.

Obviously, the last think I want is for providers to ignore patients, but true partnering requires careful listening.  Thanks to all those who listen to me with care and respect.

 

Wrap Around Care and Right to Choose

A lovely NYT article by Jessica Nutik Zitter, headed Should I Help My Patients Die? gives a whole new, to me at least, perspective on the relationship between comprehensive care and end of life choice.  As a palliative care doctor in  state that allows, with multiple protections, assistance in the end of life process, she tells of this referral:

This first patient of mine was not a simple case. When I walked into his room, he glared at me. “Are you here to help me with this aid-in-dying thing?” he asked. He was in his early 60s, thin and tired, but in no obvious distress. From my read of his chart, he met all criteria to qualify. Terminal illness, decision-making capacity, ability to self-administer the medications. And he had made the requisite first request for the drugs two weeks earlier, as procedure dictates.

When I asked why he wanted to end his life early, he shrugged. “I’m just sick of living.” I asked about any symptoms that might lie behind his request: unrelenting pain, nausea, shortness of breath. He denied them all. In palliative care, we are taught that suffering can take many forms besides the physical. I probed further and the floodgates opened.

He felt abandoned by his sister. She cared only about his Social Security payments, he said, and had gone AWOL now that the checks were being mailed to her house. Their love-hate relationship spanned decades, and they were now on the outs. His despair had given way to rage.

“Let’s just end this,” he said. “I’m fed up with my lousy life.” He really didn’t care, he added, that his sister opposed his decision.

His request appeared to stem from a deep family wound, not his terminal illness. I felt he wanted to punish his sister, and he had found a way to do it.

At our second meeting, with more trust established, he issued a sob, almost a keening. He felt terrified and powerless, he said. He didn’t want to live this way anymore.

I understood. I could imagine my own distress in his condition — being shuttled like a bag of bones between the nursing home and the hospital. It was his legal right to request this intervention from me. But given how uncomfortable I was feeling, was it my right to say no?

In the end, the patient agrees to try an anti-depressant, and dies three moths later in a nursing home.

But the real reasons for the patient’s despair are not medical, not pain, but psychosocial and emotional, with strong legal and financial elements.  These were needs that the system, notwithstanding our growing understanding of the need for multi-faceted comprehensive care, is just not yet able to provide.

This leads me to want to put the question much more starkly:

Do we have the right to force people so stay alive when we are unable to give them what thy need to have hope and meaning in their lives?

In terms of our understanding what the above described patient needs, take a look at this graphic from the recent NQF document, Strategies for Change – A Collaborative Journey to Transform Advanced Illness Care

advanced-illness-care-graphic-1016-01_fotor

I encourage a look at the full paper linked above. (This link is to my summary)  Disclosure: I provided input).

When you look at all these areas, and the much more detailed descriptions in the full paper, I would suggest you realize how far we are from meeting the needs, and therefore how inappropriate it is to force people to stay alive and suffer needlessly.  At least in the enlightened states we understand this with respect to being pain free.  How about for the other needs?

P.S.  The importance of this issue is highlighted from this study from Canada, as reported in the Washington Post, finding that the majority of those who wanted to end their lives medically were driven by psychological suffering, rather than physical suffering.

What To Expect From Death Itself, and Opportunities for Patient Partnering

I remember vividly, from when my sister was dying back in 1997 in the second hospice in the world (link to my parents’ book full text),  how important it was to my mother that when asked what she feared most, she was able to say “the death rattle” and that Dr. Robert Twycross was able to reassure her both of the insignificance of the sound, and that he would in any event make sure that it did not occur.

So, I found a new article by Doctor Sara Manning Peskin in the New York Times particularly powerful and empowering. Under the headline The Symptoms of Dying, Dr Peskin first points out that as the “letting go” gets closer, deaths become more and more similar.

You and I, one day we’ll die from the same thing. We’ll call it different names: cancer, diabetes, heart failure, stroke.

One organ will fail, then another. Or maybe all at once. We’ll become more similar to each other than to people who continue living with your original diagnosis or mine.

Dying has its own biology and symptoms. It’s a diagnosis in itself. While the weeks and days leading up to death can vary from person to person, the hours before death are similar across the vast majority of human afflictions.

Some symptoms, like the death rattle, air hunger and terminal agitation, appear agonizing, but aren’t usually uncomfortable for the dying person. They are well-treated with medications. With hospice availability increasing worldwide, it is rare to die in pain.

And, PLEASE PLEASE, note that last sentence.  Only a couple of days ago, at dinner at our retirement community, it turned out that several of our friends, informed, educated, with great access to services, still had no confidence that they would have a “good death.”

The article  (which is the first of two) then goes on to outline those various stages and symptoms the body may face: The Death Rattle, Air Hunger, and (the wrongly named) Terminal Agitation, and how they are addressed.

I guess the reason I find this relevant to patient partnering is that I think it is really important for anybody facing serious illness to be given information about all of this as soon as possible.  Having that on the table — or at least the general reassurance that it can all be managed when the time comes, will just make it far easier for an honest cooperative partnering discussion about whatever else needs to be engaged.  My guess is that most of those providing care will also become more relaxed when they know that patient and family want to know what will happen, and are willing to share their worries and have them addressed.

A Study of Why People Choose Assisted Suicide Has Important Lessons for Patient Partnering

An important article in the Washington Post should trigger some thoughts.  As the article explains:

But a study released Wednesday in the New England Journal of Medicine suggests the answers may be surprising: The reasons patients gave for wanting to end their lives had more to do with psychological suffering than physical suffering.

The study, based on information from Canada’s University Health Network in Toronto, represents all 74 people who inquired about assistance in dying from March 2016 to March 2017. Most were white and were diagnosed with cancer or a neurological disorder like amyotrophic lateral sclerosis, or Lou Gehrig’s disease.

“It’s what I call existential distress,” explained researcher Madeline Li, an associate professor at University of Toronto. “Their quality of life is not what they want. They are mostly educated and affluent — people who are used to being successful and in control of their lives, and it’s how they want their death to be.  .  .  .  One of the main things these patients bring up has to do with “autonomy.” It’s a broad philosophical concept that has to do with being able to make your own decisions, not being dependent on others, wanting to be able to enjoy the things you enjoy and wanting dignity.

The article cites several other studies that come to similar conclusions.  My first thoguht that the pain issue is easy to grasp, and a clear and dramatic focus of fear for anyone who thinks about it.  My own, perhaps overoptimistic view, is that it is a very rare case in which pain can not be satisfactorily managed provided you have access to the right experts.

But it is not the case that giving people a reason to want to live is viable for everyone.  It depends on the person, on what gives them identity, purpose and satisfaction.  If that is taken away, why on earth stay here, unless you are forced to.

When my sister, back in 1977, when given the news that (at 25) she was indeed dying of melanoma, and quickly, she asked our family physician what would happen if she asked for help dying.  His response has stayed with me all my life:  “That would mean we had failed you.”

That response works at the pain level, but it obviously works at the purpose and satisfaction level.  I would suggest that those dealing with those of us in decline should think about how to start conversations on what provides that satisfaction — and what might provide it as capacities decline.  Hopefully there is then time to learn to take please from things that have not previously given the same pleasure or purpose.

Indeed, the earlier the discussion starts, the better, and it should not be put off until the only short term outcome is death.