Should we feel embarrassed if a patient transitions to the palliative care service but then makes a good recovery?
This has happened on the stroke service. Composite case: An elderly man presents to his community hospital with a right MCA stroke and gets tPA via telemedicine. Upon transfer, he’s awake but neglectful of the left. There is right gaze preference, left hemianopia, and left lower facial paralysis with severe dysarthria. There is left hemiparesis graded 2/5.
He fails two swallow studies and we begin talking about Dobhoff tubes, maybe a PEG, likely SNF placement, etc. He has enough capacity to say, “No way!”. His family doesn’t want to see him go, but does believe that his statements are in line with his previously expressed wishes. Everyone agrees that palliative care is preferable to supportive care with a feeding tube and other medical interventions.
Two days later, on the palliative care floor, he’s laughing, talking more clearly, and eating pudding. He’s walking around the unit with a walker. Plans are made for discharge home with home health services.
So, did we mis-prognosticate? I’ve sometimes wondered that but lately I’ve been thinking that this is perfectly OK. When someone decides they’ve reached a point in their life that they prefer palliative care to life-prolonging care, it doesn’t necessarily mean that they have to die within a few days. I think we may have inappropriately drawn a tight linkage between the questions of “what treatment approach?” and “when am I ready to die?” when in fact they are sometimes–not always–very different questions.
Some of you may be familiar with this study, in which advanced lung cancer patients receiving palliative care along with conventional oncologic care lived longer than those treated only conventionally, despite receiving fewer aggressive end-of-life treatments. They also reported higher quality of life.
I also highly recommend this superb essay by a family medicine doc at USC.
So, maybe our hypothetical patient above had the best outcome possible–he lived longer than we expected, and did so without a feeding tube, LMWH injections, Accu-Cheks, and all the other minor indignities that our patients tolerate in the course of conventional medical care. Not a bad way to die.