Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

A “stat” palliative care consult: cognitive dissonance meets cognitive ignorance

Michael A. Salvatore, MD
Physician
February 28, 2018
116 Shares
Share
Tweet
Share

It was a perfectly comfortable morning when suddenly it was discomforted by a request for a stat palliative care consult. A stat consult is disquieting because “stat” is a dissonant adjective for the compound noun, “palliative care.”

“Stat” is the medical abbreviation for the Latin adverb “statim” meaning “immediately.” Stat orders always imply the necessity of an immediate response to an emergency: an inadequate blood pressure, an erratic hear rate, a falling oxygen level — all potentially life-threatening. “Palliative” derives from the Latin verb “palliare” meaning “to cloak.” Palliative care literally means to cover over with care: to alleviate without curing. Stat palliative care is a dissonant expression in any language.

In our ER was an elderly gentleman, moribund from not one but two widely metastatic cancers. His life was rapidly fading away piece by piece — hypotension, hypoxia, lethargy. By his side was an elderly gentlewoman overcome by a growing grief. Her husband of 50-some years was slipping from her grasp minute by minute. She was overwrought – what was happening, would he die, would their children arrive in time?

The ER doctor diagnosed the gentleman as a dying patient in the final act of a cancerous play in which the many metastatic actors were hurriedly dragging the living one offstage for the final curtain call. But there was no script for the final act; he had no living will, he did not have a POLST form, he was still a full code. No one had told this couple they were in the last act, no one had discussed or prepared them for the ending. So the ER doctor improvised, he called for new actors, and he wanted them on stage immediately. He called for a stat palliative care consult.

The final act was mercifully short. Yes, she knew her husband was dying in front of her eyes. No, he didn’t want heroic care under any circumstances. Yes, she wanted him comfortable above all else. No, she didn’t want to wait for their children but prayed they would arrive in time. Yes, the morphine was started. No, the children didn’t arrive before he died. No, she was not relieved her husband of so many years was dead. Then she tearfully spoke the closing lines of this cancer play, “Why didn’t somebody tell us?” Words far too often heard – more pleading than questioning.

Indeed, why hadn’t they been told? In many places, they would have been told. In many places, his death wouldn’t have been a surprise ending. In many places, the patient and the family would have suffered less. But not in all places and this is where dissonance meets ignorance.

Today no patient with advanced congestive heart failure would be denied cardiology care.  This would not be acceptable medical practice anywhere in America. But some patients suffering despite curative treatments for heart failure or a myriad of other aliments are denied palliative care. While ignorance about cardiology would be deemed unacceptable, lack of knowledge of palliative care seemingly can be the community standard. Relieving unnecessary suffering is no less a clinical responsibility than relieving pulmonary edema. Ignoring unnecessary suffering in patients mastered by their disease is like the ignoring desperate dyspnea in patients overcome by CHF. But the problem may be worse than ignorance; it may be indifference.

There seems to be an insouciant clinical myopia that clearly sees the physical symptoms of disease but is unable to focus in on the suffering the disease is causing. It is the obligation of a physician to help the patient understand the trajectory of the disease. Some doctors seemingly have an apathetic nearsightedness that only sees the problems in their clinical neighborhood. They are not uncaring but something worse: they are blind to the patient’s suffering.

Every doctor has the instinctive reflex to immediately staunch the hemorrhage of a bleeding patient. Regrettably, there seems not to be an analogous instinct to staunch suffering of an anguishing patient. Why? Is it a lack of education, a lack of expectation, and a lack of empathy?  Why the discomfort to discuss dying? Myriads of workshops, symposia, and articles have explored this problem. Some have supposed that educational deficiencies leave physicians feeling unprepared and lacking confidence to discuss death. Others conclude many physicians have an abiding reluctance to accept that treatment cannot be in the patient’s best interest. Others regard death as a failing. Most concerning is that some doctors just fail to recognize the terminal stage of diseases; they are just ignorant of it.

There is another matter that the physician-author Abraham Verghese put his literary finger on in two simple sentences: “In medicine, as in writing, there are no shortcuts. You need stamina.” But stamina is increasingly in short supply in clinical medicine. It being is sapped away by the stresses of electronic, legal, financial, and insurance demands.   Delivering bad news can be brutal to the tellers and the hearers. So many physicians seek to avoid what they feel to be brutalizing encounters but in doing so, they brutalize the suffering patient even more.

It is not the avoidance, but the acceptance that relieving suffering is compassionate, merciful, and rewarding for both the doctor and the patient. Not knowing this is the ignorance that results in stat palliative care consults — not knowing that relieving the suffering of patients fulfills a physician’s humanity. The real dissonance is that it withers a doctor’s clinical heart not to unburden patient from a suffering that is in their power to relieve.

We live in a medical world where many patients continue to endure insufferable disease states. Some might think that stat palliative care is better late than never. It is not because it is no longer palliative care, because the time for palliative care is gone and missed, just like the elderly gentleman in our ER.

Michael A. Salvatore is a palliative care physician.

Image credit: Shutterstock.com

Prev

Physicians don't know everything, and that's OK

February 27, 2018 Kevin 3
…
Next

Patients lose when physicians burn out

February 28, 2018 Kevin 8
…

Tagged as: Emergency Medicine, Hospital-Based Medicine, Palliative Care

Post navigation

< Previous Post
Physicians don't know everything, and that's OK
Next Post >
Patients lose when physicians burn out

More by Michael A. Salvatore, MD

  • The physician-assisted suicide predicament

    Michael A. Salvatore, MD
  • Shakespeare on palliative care

    Michael A. Salvatore, MD
  • Barbara Bush: The First Lady of palliative care

    Michael A. Salvatore, MD

Related Posts

  • A letter to a cancer patient in palliative care

    Alison Vasa
  • How social media can help or hurt your health care career

    Health eCareers
  • Why health care replaced physician care

    Michael Weiss, MD
  • Turn physicians into powerful health care influencers

    Kevin Pho, MD
  • Care is no longer personal. Care is political.

    Eva Kittay, PhD
  • Primary Care First: CMS develops a value-based primary care program for independent practices

    Robert Colton, MD

More in Physician

  • Decoding name displays in health care: Privacy, identification, and compliance unveiled

    Deepak Gupta, MD
  • Master time management with 7 productivity strategies for optimal results

    Farzana Hoque, MD
  • The tragic story of Mr. G: a painful journey towards understanding suicide

    William Lynes, MD
  • The escalating violence in health care workplaces: a critical problem facing the nation’s health care system

    Harry Severance, MD
  • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

    Howard Smith, MD
  • Why allowing yourself to embrace discomfort is necessary for personal growth

    Jillian Rigert, MD, DMD
  • Most Popular

  • Past Week

    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
    • Boxing legends Tyson and Foreman: powerful lessons for a resilient and evolving health care future

      Harvey Castro, MD, MBA | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
  • Past 6 Months

    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
  • Recent Posts

    • Unveiling the global pandemic threat: insights into risk factors and urgent measures for prevention

      Ton La, Jr., MD, JD | Policy
    • Decoding name displays in health care: Privacy, identification, and compliance unveiled

      Deepak Gupta, MD | Physician
    • Empowering Black nurses for lasting change [PODCAST]

      The Podcast by KevinMD | Podcast
    • Master time management with 7 productivity strategies for optimal results

      Farzana Hoque, MD | Physician
    • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

      Hoag Memorial Hospital Presbyterian | Conditions
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Novel Anti-HER2 Drugs 'Impressive' in Advanced Biliary Cancer
  • What Was Tied to Lower Long COVID Risk?
  • Chemo-Free Approach Works in Subset of Patients With HER2+ Early Breast Cancer
  • Two-Drug Combo Wins for Refractory Gout
  • First-in-Class Sjogren's Drug Passes Mid-Stage Test

Meeting Coverage

  • Novel Anti-HER2 Drugs 'Impressive' in Advanced Biliary Cancer
  • Chemo-Free Approach Works in Subset of Patients With HER2+ Early Breast Cancer
  • Two-Drug Combo Wins for Refractory Gout
  • First-in-Class Sjogren's Drug Passes Mid-Stage Test
  • Pricey Drug Combo Boosts PFS in First-Line Advanced Ovarian Cancer
  • Most Popular

  • Past Week

    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
    • Boxing legends Tyson and Foreman: powerful lessons for a resilient and evolving health care future

      Harvey Castro, MD, MBA | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
  • Past 6 Months

    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
  • Recent Posts

    • Unveiling the global pandemic threat: insights into risk factors and urgent measures for prevention

      Ton La, Jr., MD, JD | Policy
    • Decoding name displays in health care: Privacy, identification, and compliance unveiled

      Deepak Gupta, MD | Physician
    • Empowering Black nurses for lasting change [PODCAST]

      The Podcast by KevinMD | Podcast
    • Master time management with 7 productivity strategies for optimal results

      Farzana Hoque, MD | Physician
    • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

      Hoag Memorial Hospital Presbyterian | Conditions
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...