Monday, 14 March 2016

End of life: the outstanding professional debate

@kevinmd’s tweet takes us to a post signed by the oncologist James Salwitz, a professional who’s very active on the internet and has his own blog: “Sunrise Rounds”. Although I feel that I've devoted a lot of attention to the issue of end of life, I have decided to choose the letter from Dr. Salwitz because it seems to me that he has managed to go straight to the point on a professional debate that we have not yet solved, nor are we close to solving.

Dr. Salwitz explains that in a workshop on pain and depression control, one of the participating general practitioners raised his hand and said: "I believe that this drift towards palliative medicine will send us back to the dark ages as we will forget to defeat disease while medical research will no longer make sense, which may be the end of modern medicine and of the way of life specific to our society." The dilemma, then, according to this colleague is crystal clear, as Dr. Salwitz says: "Either we fight with all our strength against death, injecting chemotherapy to all patients, regardless of their view on life, or we surrender to the evidence that we are mortal and we accept the Darwinian principles of species while preparing to die with dignity."

The confrontation between the two concepts: a) "we have to fight up to the end", and b) end of life palliative care, is represented at the top of the graph of the report "Delivering high quality cancer care" of IOM. But what would be of interest to modern medicine and to patients should be a continuum of care as shown at the bottom of the same graph. This means there can be no healing medicine which only gives way to palliative medicine when it throws the towel, but an agreement between the two visions ought to be clearly tailored to the needs of each person.

Recently, the Washington Post broadcasted a case: "The doctor who didn’t know when to stop the treatment" related by Dr. Diane Meier, Director of the Centre for Palliative Care at Mount Sinai Hospital in New York. If you didn’t read it at the time, use the link provided to read it now. You’ll see how this case illustrates exactly the dilemma that Dr. Salwitz went through in his workshop.

Jordi Varela


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