CancerWorld: Framing the argument over futile care - overdiagnose, overtreat, overpromise...media focus

Framing the argument over futile care:

We “overdiagnose, overtreat and overpromise”. This was the claim made by numerous newspaper headlines in response to the Lancet Oncology report last September on delivering affordable cancer care. While we do need open and frank discussions about how to curb the spiralling costs of cancer care, it was unfortunate that the media focused so heavily on the cost of futile treatment in the last weeks of life, blaming it all on a culture of excess. This sparked reports that patients would be denied potentially life-prolonging treatments purely on the basis of cost and generated fears that patients might be abandoned in their final months. There is no doubt that we do overtreat and overpromise in the advanced cancer setting. We know, for instance, that many patients receive cancer treatments in the last weeks of their life, and that some of these treatments have no reasonable chance of helping the patient and are associated with severe side-effects that can lead to hospitalisation and even death. We also know that receiving chemotherapy is associated with a delay in referral to palliative care. But blaming this on a culture of excess is too simplistic. Making the right decisions in later stages of advanced cancer is difficult for doctors and patients alike. It is often impossible to predict how long a patient will live, and while we have an increasing number of therapies to choose from, we don’t yet know enough about who stands to benefit and by how much. There can be a huge disconnect between the expectations of patients and families and those of clinicians, adding to the difficulty of conducting honest conversations with patients about their prognosis, treatment options and end-of-life preferences. There are no easy answers. But could we be making things harder for ourselves by posing options in terms of a choice between either fighting cancer or optimising quality of life? An emerging body of evidence shows that integrating palliative care into the mainstream care of cancer patients not only improves their quality of life, but might even help them live longer. Early involvement of palliative care specialists has also been shown to cut down on futile medical interventions and help families cope better with their loss of a loved one. ASCO is now recommending that patients should be offered concurrent palliative care and standard cancer treatments early in the course of their advanced cancer journey. This is in line with efforts to stimulate meaningful interaction between mainstream oncology and palliative care specialists that ESMO and other European professional bodies have been pursuing for some time. However, progress so far has been infuriatingly slow. Greater integration of palliative care requires changes in the way we organise care and train clinicians. We need to get on with this as a matter of urgency. If we fail to take a lead in addressing shortcomings in the way we care for patients with advanced cancer, the simplistic arguments about a wasteful culture of excess could win, and patients will be the losers.

Association for Psychological Science (Harvard): Is modern medicine ill with dehumanization?

Is modern medicine ill with dehumanization?

New article offers a diagnosis, unveils its causes, and prescribes a humanizing cure

"Anyone who has been admitted into a hospital or undergone a procedure, even if cared for in the most appropriate way, can feel as though they were treated like an animal or object," says Harvard University psychologist and physician Omar Sultan Haque. Health care workers enter their professions to help people; research shows that empathic, humane care improves outcomes. Yet dehumanization is endemic. The results can be disastrous: neglect of necessary treatments or prescription of excessive, painful procedures or dangerous drugs.

What are the causes and effects of dehumanization in medicine? And what can be done about it? In Perspectives in Psychological Science, a journal of the Association for Psychological Science, Haque and co-author Adam Waytz at the Kellogg School of Management of Northwestern University synthesize diverse literatures to distinguish when dehumanization is useful from when it is not. Then they recommend "simple, cheap, and effective" changes to "make medical institutions more humane and ethical, as well as efficacious in the service of improved health," says Haque.

The structures of institutions and the psychological demands of providing care can cause professionals to treat patients as less than human. "Deindividuation"—doctors as a sea of white coats; patients as half-naked bodies in smocks, identified by their disease or procedure ("the gallbladder in Room 38")—allows staffs to avoid taking responsibility for each patient. "Impaired patient agency" refers to medical staffs' treatment of patients as incapable of planning their own care, which is both infantilizing and demoralizing. "Dissimilarity"—hierarchies of power, differences of race, class, and gender between staff and patients—have roots outside the hospital. Nevertheless, they cause miscommunication and alienation, even maltreatment. None of these practices serves good medical care.

More complex are dehumanizing practices that may aid care. Diagnosis and treatment might necessitate "mechanization"—breaking the body into organs and systems. Scaling back empathy can diminish staff stress and burnout. Even moral disengagement can be adaptive. From giving a shot to slicing into the flesh to perform surgery, medical care often requires inflicting pain or invading the boundaries of the body in violation of deeply held human taboos. And patients may die after even the best of care. For the professional, guilt could be paralyzing.

Still, the authors argue, dehumanization is useful only in "specific contexts," such as acute care. Waytz says, "Dehumanization's functionality varies wildly across specialities from pediatrics to orthopedic surgery, so future research is needed to determine when dehumanization is most prevalent and most detrimental." In the meantime, the authors offer numerous humanizing fixes: Call patients by name, not numbers; discourage labeling people as diseases; personalize hospital rounds and pre-surgical preparation; eliminate opaque surgical masks; affix photos to CT scans and biopsies. Include patients in care planning. Let them choose their gowns—and design those gowns so they're no so humiliating. Increase physician diversity and hire people with good social skills. And, for med schools, perhaps most radical: Eliminate the "white-coat ceremony" when graduates don the mufti of the elect.

Finally, "we should train medical professionals to think of themselves as mortal – sharing a common humanity and vulnerability with their patients," says Haque. Although dehumanization can be useful, "even functional dehumanization should be viewed like a potent, salutary, but dangerous drug that can have disastrous side-effects" when overprescribed.

Arch Intern Med -- Abstract: Intensive Care Unit Bed Availability and Outcomes for Hospitalized Patients With Sudden Clinical Deterioration (Calgary, Alberta)

Arch Intern Med -- Abstract: Intensive Care Unit Bed Availability and Outcomes for Hospitalized Patients With Sudden Clinical Deterioration

ONLINE FIRST Intensive Care Unit Bed Availability and Outcomes for Hospitalized Patients With Sudden Clinical Deterioration

Background  Intensive care unit (ICU) beds, a scarce resource, may require prioritization of admissions when demand exceeds supply. We evaluated the effect of ICU bed availability on processes and outcomes of care for hospitalized patients with sudden clinical deterioration.

Methods  We identified consecutive hospitalized adults in Calgary, Alberta, Canada, with sudden clinical deterioration triggering medical emergency team activation between January 1, 2007, and December 31, 2009. We compared ICU admission rates (within 2 hours of medical emergency team activation), patient goals of care (resuscitative, medical, and comfort), and hospital mortality according to the number of ICU beds available (0, 1, 2, or >2), adjusting for patient, physician, and hospital characteristics (using data from clinical and administrative databases).

Results  The cohort consisted of 3494 patients. Reduced ICU bed availability was associated with a decreased likelihood of patient admission within 2 hours of medical emergency team activation (P = .03) and with an increased likelihood of change in patient goals of care (P < .01). Patients with sudden clinical deterioration when zero ICU beds were available were 33.0% (95% CI, –5.1% to 57.3%) less likely to be admitted to the ICU and 89.6% (95% CI, 24.9% to 188.0%) more likely to have their goals of care changed compared with when more than 2 ICU beds were available. Hospital mortality did not vary significantly by ICU bed availability (P = .82).

Conclusion  Among hospitalized patients with sudden clinical deterioration, we noted a significant association between the number of ICU beds available and ICU admission and patient goals of care but not hospital mortality.

open access: Goal-Oriented Patient Care — An Alternative Health Outcomes Paradigm — NEJM

"Ultimately, good medicine is about doing right for the patient. For patients with multiple chronic diseases, severe disability, or limited life expectancy, any accounting of how well we're succeeding in providing care must above all consider patients' preferred outcomes."

Multinational Comparisons of Health Systems Data, 2011 - The Commonwealth Fund including link to 2011 patient care coordination (11 countries)

"International comparisons of health care systems offer valuable tools to health ministers, policymakers, and academics wishing to evaluate the performance of their country's system. In this chartbook, we use data collected by the Organization for Economic Cooperation and Development (OECD) to compare health care systems and performance on a range of topics, including spending, hospitals, physicians, pharmaceuticals, prevention, mortality, quality of care, and prices. We present data across several industrialized countries: Australia, Canada, Denmark, France, Germany, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. Whenever possible, we also present the median value of all 34 members of the OECD.......

Downloads

• Chartbook (248K PDF)
• • Chartbook (626K PPT) 

    Related

    • In the Literature
      • New 2011 Survey of Patients with Complex Care Needs in Eleven Countries Finds That Care Is Often Poorly Coordinated

full free access: Genomics and the Continuum of Cancer Care — NEJM (long article covering differing concerns)

What makes a good doctor? The Lancet

Blogger's Note: the discussion regarding education/system/research/focus would be an appropriate concern for all those involved with direct patient care and not exclusive to doctors

Patient Willingness to Be Seen by Physician Assistants, Nurse Practitioners, and Residents in the Emergency Department: Does the Presumption of Assent Have an Empirical Basis? - The American Journal of Bioethics

Note: the journal has a number of similar papers regarding this issue, however, this is a subscription/pay-per-view journal without access to abstracts in many cases

Editorial: Who Are We and Where Are We Headed? Journal of Oncology Practice

Note: factors/needs affecting physicians taking care of patients