The setting: A medical conference exploring the use of Asian therapiesfor cancer.
The cast: Oncologists, cancer researchers, and healers of alldescriptions as well as cancer patients and one bald and robed Buddhist chaplain.
The topic under discussion: The seemingly dispassionate manner of somedoctors in their dealings with terminal patients.
Amidst murmurs of agreement (cold! uncaring!) from theaudience, a medical oncologist rises to express the view from his sideof the bedside [red.]. "Patients, even terminal patients, seem to have no tools to help them make sense of death," he muses. "How did I get here?" these patients wonder as they approach death's door. "What does it mean?"
The oncologist's question: Can I really be faulted for not having those answers? And isn't it just a little late to start grappling with spiritual issues of this magnitude with five minutes left on your clock?
Quickly, the sentiment in the room swings in favor of the harrieddoctor who, true to the tradition of triage, must turn his attention tothe lives he can save, even while turning his back on the one he can't.There's no IV feed that delivers to dying patients the meaning oflife, adds another doctor in the room. It's what they need and I just don't have it.
Although it's certainly true that some doctors are too busy or toodetached to help patients grapple with end-of-life issues, that's not the real problem, concurs panelist Leslie Blackhall, M.D. Rather, our culture simply doesn't seem willing to accept death as an outcome, she says. The prevailing wisdom in modern-day America is that death is what happens to a small group of unfortunate people--no one we know, says Blackhall, who is the medical director of the Center for Geriatrics and Palliative Medicine at the University of Virginia School of Medicine. "Well, I'm sorry but that's a really distorted worldview."
A competing view, equally distorted, is the off-button concept ofdeath, says Blackhall, and it goes something like this: You walk arounduntil you're 90 years old being Herb or Gloria--totally Herb or trulyGloria until, at 90, your off button's pushed and you die. Cancerdoesn't allow for that, says Blackhall. Cancer can mean a long, slowdecline during which you lose various pieces of your identity, she says.
Some of the big ones: your ability to pursue your profession, your appearance, your hair. Near the end, you can't even get out of bed. And yet you're alive. But who are?
Last year, when journalist Bill Moyers explored end-of-life issues inhis PBS program "On Our Own Terms: Moyers on Dying," he came to realizethat Americans viewed death as unAmerican.
"We Americans don't like limits, we don't like boundaries. And death is the ultimate boundary," he said in a post-program online chat. "We've also put death at arm's distance," he says. "When I was a kid, people died at home. My grandfather died at home. I saw his body stretched out on the table in the parlor of my grandmother's little house. But then we started sending people off to the hospital to die. They died out of sight, in the care of strangers.... We've just put a distance between us and death."
Palliative Care and Hospice
The bad news first: Over 50% of patients who die in a hospital are inmoderate or severe pain in the days before their deaths, says Cynthia Pan, M.D., citing the well-regarded Support Study, whichsuggests that in many ways, as a patient's remaining days dwindle, sodoes a hospital's quality of care.
Pan, however, is quick to defend doctors' efforts to work to the bestof their abilities. "People go into medicine with the intention to dogood," affirms Pan, who is the director of the Edward HertzbergPalliative Care Institute at the Mount Sinai School of Medicine in NewYork City. "But some doctors are never taught the adage 'to curesometimes, to comfort always.'"
That mandate sums up Pan's specialty--and offers a solution to poorquality of life at life's end: Palliative care, while not withholdingtreatment, looks at the whole patient, including her pain, hersuffering, her psychological needs, aiming more to relieve than tocure, she says. Currently, palliative care training is offered in lessthan 10% of all medical schools in this country, says Pan, who is partof an initiative to make palliative care required course work.
The Rev. Madeline Ko-i Bastis, the first Buddhist in America to beBoard-certified as a health-care chaplain, agrees that physicians arebetter trained to cure than to comfort. Doctors are hardwired to savelives, fighting with every fiber to extract another breath out of theirpatients--and then another one after that, says Rev. Bastis, whoestablished the Peaceful Dwelling Project in East Hampton, New York, which offers meditation workshops and retreats for people with life-threatening illnesses and their caregivers. Giving into death is precisely what doctors are trained not to do, she says.