Guess what happened on the way to the cemetery?

As a hospice chaplain, there is a saying in the industry that goes something like this; "Don't forget to tell the hearse to stop for his last chemotherapy treatment on the way to the cemetery." As cold as this sounds, every exaggeration has a point that comes from a certain amount of truth. The article by MSNBC, entitled "Cancer docotors don't know when to give up" ,linked to this entry, identifies one of the key medical issues in the treatment of patients at the end-of-life. As our knowledge and technology advances in medicine, it appears that continuous healing is just a matter of finding the correct technology or most recent miracle drug to eliviate the problem. So the trend is for physicians to continue treating cancer patients as late as the last two weeks of life when it really doesn’t help.

So you ask, why are physicians doing this if there is no healing benefit to it and it causes the patient to suffer the side effects of chemotherapy? The Hippocratic Oath of non-malfeasance, that every doctor takes, states that the physician will do no harm in the process of practicing medicine. "Overly aggressive treatment gives false hope and puts people through grueling and costly ordeals when there is no chance of a cure, cancer specialist said.”1

The answer is that physicians spend most of their time diagnosising and healing patients. They do this for their patients from the time of birth until death. So it follows that physicians are just as uncomfortable with talking about death with a patient as anyone else. However, though most of us really don’t have to deal with death if we chose not to, physicians have to be trained to understand that death is a part of life. The end part of life that a physician has accepted as part of his/her responsibility, needs to be addressed by doctor’s orders for hospice care, pain and symptom management, in the final six to twelve months of a patient’s life.

It is a natural assumption for most of us to make, that our healthcare facilities (inclusive of hospitals, nursing homes, long term care facilities, and assisted living facilities) are knowledgeable about pain and symptom management at the end of life. This simply is not the case today. Providing care for those who are actively dying is a specialized field, just as providing nursing for patients in an emergency room, a labor and delivery floor, and that of a surgical and neurological intensive care floor are all different. We would not expect an orthopedic surgeon to deliver babies, yet we consider all nursing skills as being equal. A nurse is a nurse, right? Wrong. As one example, when a person is actively dying the issue of addiction to pain medication is no longer an issue and the pain experienced in life and in the dying process is different. As another example, normally a nurse would suggest that we encourage a patient to eat and drink. However, in the dying process, it is natural to stop eating and drinking as part of the transition from one world to another.

By physicians providing such orders, the physician can give the patient the specialized treatment required at the end-of-life. However all of these services are foregone when a physician is not trained to identify the moment when medical cures have reached their limits and the fact that the patient is going to die. On the contrary when the order is written for hospice care, the physician opens up a whole new set of services. Services provided by multiple disciplines that are specialists in end-of-life issues. Items that hospices can provide include: spiritual support; psychological and emotional support, nursing and nursing assistance to provide relieve, education and general help to the caregiver, music therapy, Reki massage, life stories, advance directives, and volunteer services just to mention a few. By the physicians facing their own fears, they have the ability to provide the most complete set of services especially to those who are dying.

1. The Associated Press. “Cancer Doctors don’t know when to give up.” MSMBC.com, June 7, 2006. http://www.msnbc.msn.com/id/13105178/from/ET/ (accessed 11/20/2006)