Therapeutic Palliation

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.

About Justin A. Sattin

I'm a vascular neurologist and residency program director. I created this blog in order to share some thoughts with my resident and other colleagues, and to foster my own learning as well.
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6 Responses to Therapeutic Palliation

  1. Khalid Alsherbini says:

    I totally agree Dr. Sattin , i think going to palliative does NOT mean the patient is going to die , and we have to understand this when we counsel families, it’s just choosing different way to treat and concentrate more on comfort measure, which in medicine “wait and see” is actually a way of therapy.
    on the other hand, same thing applies for hospice, as i like the definition that ” who is the patient that would be considered for hospice ” and i like the answer that says ” the patient who dies in 6 months would not be a surprise ” so when we send patients to hospice that does not mean they are going to die in couple days, but it only means that they have high mortality rate in the next 6 months .
    JUST a THOUGHT !!!

  2. Aaron says:

    This is an important concept that has evolved in my mind over the course of residency. At the beginning of my PGY-2 year my concept of palliative care was essentially that is was a disposition option for the sickest patients and once it was signed, it allowed for a personal shortening of sleep latency time.

    But through several cases with some similar to Dr. Sattin’s description, as well as the short course taken with Dr. Campbell regarding difficult patient conversations. I see palliative care more as a personal choice reached by a patient at a certain stage in life. It is when they decide to draw the line in the sand and say I will not cross. Maybe it is a feeding tube, maybe it is surgery, eventually it may become IVF and abx.

    The measurement of the ratio between quality and quantity of life becomes delicate as both entities become scarce and expensive. While we can assist in trying to quantify these, our predictive abilities are limited, and we must be humble in our assessments. An equally important task for the physician is to frame the situation and acknowledge the uncertainty inherent to medicine. Then through careful questioning and by providing concrete examples and concrete choices the decisions can be made. If this is done properly I am able to feel comfortable independent of the outcome.

    An example would be an elderly patient that suffered a moderate sized hypertensive hemorrhage. After a week of persistent encephalopathy, but stable head CT, it became evident that he was unlikely to directly die from his disease, and it was unclear how much permanent disability he would suffer. It was discussed with the family about placement of feeding tube and transfer to an LTAC. The family declared that the patient clearly stated he never wanted a tube nor to be an a nursing home even if only temporarily. The patient was then transitioned to palliative care. His mental status improved over several days and he was able to keep his eyes open and direct some attention to his family, he never attempted to eat on his own. This condition last for another week then he passed.

    I think his improvement after transfer out of the unit does not mean that the decision was inappropriate. The decision to not place a feeding tube and continue life sustaining care even in a patient with reasonable chance of recovery is also appropriate. In the realm of the fuzzy calculus use to weigh the essence of life, the man had drawn a concrete line where the chance for longer quantity of life was no longer justified by a decrement in quality of life no matter if even temporary. This is one equation where every person gets to be there own Godel.

  3. Jim Cleary says:

    Justin, Well written piece and good comments.
    Couple of thoughts.
    1) Please keep the ‘care’ in “palliative care.” So many things can be passed off as having a palliative intent. “Palliative Care” has a clear definition and we should always refer to it as such. It can be provided in many settings: home, inpatient, nursing home or a hospice.
    Let me add another thought in reference to the Temel study (Life prolongation from palliative care in advance lung cancer patients). Much has been made about this even by palliative care practitioners. But let me suggest that the focus on a survival is caving into the “industrial medical complex.” Palliative care by intention neither intends to prolong life, nor hasten death. It is as your example shows, focusing on quality of life.
    Thanks for the opportunity to contribute…

    • Justin A. Sattin says:

      Good point about the Temel study. Maybe instead of saying “. . . lived longer and oh by the way had better quality of life” I should have said, “had better quality of life and oh by the way lived longer”.

  4. Toby Campbell says:

    People frequently talk to me about the notion of “giving up.” People often mention not wanting to give up too soon (or at all). However, upon further discussion, they more often want to avoid the perception that they gave up too soon. So it’s relatively common for patients to want to push on to be strong for their loved ones. I also push past the “I want to fight” comments.

    Here’s an example from a couple weeks ago of my memory of an exchange which is pretty common for me:
    Pt: I’m a fighter, doc. You can give me whatever you need and I’ll take it.
    Dr: I’m very impressed by your strength. You’ve already done everything we’ve asked and done it with a smile. I’m curious, tell me what you’re fighting so hard for?
    Pt: Well, to live longer of course.
    Dr: Yes, yes; I guess I mean, what do you live for? You know, what makes you happy?
    Pt: Hmm, well I really want to spend more time with my kids and grandkids.
    Dr: That sounds wonderful. Let’s say our hopes came true and treatment works and you do have more time – what would you do with it?
    Pt: Gosh, I would probably go on another camping trip with my grandkids and tell them all about the world. I’d try to really set them straight.
    Dr: Wow, I bet they would really appreciate both spending time with you and learning from you. What’s stopping you from teaching them those lessons now?
    Pt: Well, I guess just the fact that here we are fighting and all, and it doesn’t feel like the right time. I guess you’re saying I could talk to them now?
    Dr: [silence, maybe a shrug, just letting him work this through]

    He went on to realize his attachment to treatment was distracting him from what he really hoped and cared for.

    My advice for all of us is to be courageous enough to sit down and step into the role of a healer by explore more about what are patients are hoping for. In the pursuit of this intimate knowledge I find my relationships strengthened, my therapeutic value expanded, and my own satisfaction enhanced.

  5. Vikas Singh says:

    I agree with the “keep the care part in palliative care” and “had better quality of life and oh by the way lived longer”.

    Many a times there is a controversy or I would say some confusion regarding keeping the care part. Palliative by definition means relieving and preventing the suffering of the patients – be it secondary to the illness that brought them to this crossroads or from the treatments options that can be used. It neither postpones nor hastens death. It just provides the patient and the family the right atmosphere and interventions to cope with the illness and suffering. The patient does not undergo heroic measures to “sustain or prolong life” but can still get the usual, customary and reasonable care. This in turn leads to them have a “had better quality of life and oh by the way lived longer”.

    These principles often get blurred in busy inpatient settings when the patient is very sick. Best use of palliative care principles can be seen in our oncological or terminal heart failure or liver disease patients undergoing the same in the outpatient setting, at LTC facilities and the inpatient side has a bit to catchup.

    As mentioned in Ken Murray’s essay, I would be DNR/DNI when the time comes 🙂 Save the misery, save the money.

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