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.
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