Sunday, September 05, 2010

Limbaugh/Palin "death panels" extend the lives of terminally ill patients

What is palliative care? Until quite recently, it's something I haven't given much thought. Although there was a highly regarded article on hospice and palliative care by Atul Gawande in last month's New Yorker, I didn't read it or think it applied to my life. All that changed less than two weeks ago, when my father was hospitalized in critical condition after collapsing. First he went to the ER, then the transitional ICU, and finally he was placed in the palliative care unit by the time I arrived. You see, my father has metastatic lung cancer, for which he had refused treatment for more than a year. Instead, he decided to stay home with my mother, watch DVDs, go out to eat, and do yard work.1

A recent paper in the New England Journal of Medicine demonstrated that the introduction of palliative care shortly after the diagnosis of metastatic lung cancer not only improved the patients' quality of life, but also extended median survival from 8.9 months to 11.6 months (Temel et al., 2010). According to the American Academy of Hospice and Palliative Medicine:
The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Palliative care is both a philosophy of care and an organized, highly structured system for delivering care. Palliative care expands traditional disease-model medical treatments to include the goals of enhancing quality of life for patient and family, optimizing function, helping with decision-making and providing opportunities for personal growth. As such, it can be delivered concurrently with life-prolonging care or as the main focus of care.
This finding is critically important for providers of medical care for terminally ill cancer patients as well as for health policy, because it provides categorical, scientific proof that the notion of "death panels" is false. As stated in the New York Times:
“It shows that palliative care is the opposite of all that rhetoric about ‘death panels,’ ” said Dr. Diane E. Meier [@DianeEMeier], director of the Center to Advance Palliative Care at Mount Sinai School of Medicine and co-author of an editorial in the journal accompanying the study. “It’s not about killing Granny; it’s about keeping Granny alive as long as possible — with the best quality of life.”
A straw man in the 2009 health care debate, "death panels" invoked the specter of rationing medical procedures provided for the sick and the elderly. In the name of cost cutting, blared the phony rhetoric on talk radio and Sarah Palin's Facebook page, the Obama administration would sanction euthanasia for elders and the terminally ill under provisions of the health care bill. This would save on expensive treatments that prolong patients' lives but increase the deficit, claimed the conservative crew. However, these scare tactics were an outright lie, as we learn from the Wall Street Journal:
Palin’s “Death Panels” Charge Named “Lie of the Year”

...

“Of all the falsehoods and distortions in the political discourse this year, one stood out from the rest,” writes Politifact.com, the non-partisan, Pulitzer Prize-winning site run by the St. Petersburg Times. Palin’s “assertion — that the government would set up boards to determine whether seniors and the disabled were worthy of care — spread through newscasts, talk shows, blogs and town hall meetings.”

“Opponents of health-care legislation said it revealed the real goals of the Democratic proposals. Advocates for health reform said it showed the depths to which their opponents would sink,” Polifact.com says.

The NEJM study enrolled 151 patients with newly diagnosed metastatic non–small-cell lung cancer. Seventy-four received standard care and 77 patients received palliative care, which included meetings with a member of the palliative care team (board-certified palliative care physicians and advanced-practice nurses). The first meeting was within 3 weeks of enrollment, and subsequent meetings were held on a monthly basis, with additional sessions at the discretion of the patient and the clinical treatment team. Patients assigned to standard care did not meet with the palliative care team (unless requested). All patients continued to receive standard oncology care for the duration of the study.

These meetings are the so-called "death panels" that would have been covered by Medicare, as mentioned by the NYT in Palliative Care Extends Life, Study Finds:
During the debate over President Obama’s 2009 health care bill, provisions to have Medicare and insurers pay for optional consultations with doctors on palliative and hospice care led to rumors, spread by talk-show hosts like Rush Limbaugh and Glenn Beck and by the former vice-presidential candidate Sarah Palin, that the bill empowered “death panels” that would “euthanize” elderly Americans. [emphasis mine]
The primary outcome measure of the study was quality of life at 12 weeks (compared to baseline), as assessed by the Functional Assessment of Cancer Therapy–Lung (FACT-L) scale. Mood was assessed using the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire 9 (PHQ-9).

Results indicated that patients in the palliative care group had a significantly higher quality of life at 12 weeks (see Table 2) and a lower incidence of depression (but similar levels of anxiety).

[click on Table for larger image]

Table 2 (Temel et al., 2010). Plus–minus values are means ±SD. Quality of life was assessed with the use of three scales: the FACT-L scale, on which scores range from 0 to 136, with higher scores indicating better quality of life; the lung-cancer subscale (LCS) of the FACT-L scale, on which scores range from 0 to 28, with higher scores indicating fewer symptoms; and the Trial Outcome Index (TOI), which is the sum of the scores on the LCS and the physical well-being and functional well-being subscales of the FACT-L scale (scores range from 0 to 84, with higher scores indicating better quality of life).

In addition, patients in the palliative care group lived longer:
Despite receiving less aggressive end-of-life care,2 patients in the palliative care group had significantly longer survival than those in the standard care group (median survival, 11.6 vs. 8.9 months; P=0.02).
The study has its limitations, however, as noted by Dr. Meier in Palliative Care: We Still Have a Lot to Learn:
...The patients (and doctors) were not blinded to their treatment group, that is, they knew which group they were in, which could have affected their outcomes. Also, there was no “attention-control” group—a group that got the same amount of human time and attention that the palliative care group got but without the palliative care skill and expertise.
Nonetheless, the purpose and goals of palliative care cannot be understated. As I mentioned in my previous post (Ketamine for Depression: Yay or Neigh?), reducing the pain and suffering of terminally ill patients is of utmost importance. Watching a terminally ill loved one suffer from unbearably excruciating pain is one of the most emotionally wrenching experiences you'll ever have. Anything, and I mean anything, that will relieve this sort of suffering (including heroin) should be administered without reservation or stigma. The options offered by hospice and palliative care should be made freely available to patients as part of a comprehensive health care plan. But Sarah Palin is still spewing her falsehoods a year after she started, despite all the evidence to the contrary.

UPDATE Sept 6, 2010: My father died at 12:30PM today. I'll miss him terribly.


Footnotes

1 In other words, he chose to live as normally as possible.

2 Aggressive care was defined as chemotherapy within 14 days before death; no hospice care; or admission to hospice 3 days or less before death.

Reference

J.S. Temel et al. (2010). Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. N Engl J Med, 363, 733-742. 10.1056/NEJMoa1000678

Additional Reading from Pallimed blog:

Game Changer: Early Palliative Care for Lung Cancer Patients Improves QOL AND Median Survival

You had me at 'improves HRQOL'...

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14 Comments:

At September 06, 2010 10:11 AM, Anonymous Anonymous said...

The death panels are not a lie, they are something that will happen if the scheme to socialize medicine (which is the inevitable end result of the disaster Obama is cooking up) succeeds.

Death panels already exist in England, Holland and other countries with socialized medicine. People are allowed to die if they are not deemed valuable enough in terms of how much more taxes and votes they can hand over to the government. This of course was routine in the Soviet Union and has become routine in most of Europe as it has followed the USSR's economic programs a bit at a time.

Palliative care has nothing to do with the inevitability of governments cutting costs by letting people die.

Stop trying to obfuscate the issue, you're not fooling anyone. Socialized medicine, currently euphemized as "universal health care", means the murder-by-neglect of anyone the government doesn't feel like keeping alive.

 
At September 06, 2010 6:41 PM, Blogger The Neurocritic said...

YOU and your pathetic misguided ilk are the ones trying to obfuscate the issue. "Death panels" do NOT exist in England and the Netherlands. In fact, YOU are acting as a death panel for the uninsured. Do you plan to pay all medical care for the uninsured out of your own pocket? If not, then who will, besides the government? Oops, looks like you've just condemned them to die.

As for your false accusation that palliative care is a separate issue, the only measure that would have been included in the health care bill was "provisions to have Medicare and insurers pay for optional consultations with doctors on palliative and hospice care."

So you're NOT in favor of alleviating the suffering of dying patients with completely incurable diseases? Metastatic non–small-cell lung cancer is inevitably fatal. There is no cure. It involves an excruciating amount of pain. Are you prepared to prolong the suffering of a terminally ill family member, rather than opt for consultation with palliative and hospice care, whose main purpose is to alleviate suffering and improve quality of life?

My father freely chose to live his final days in hospice. It's what he wanted. What I want as a neuroscientist is the use of all currently available drugs to help control pain at the end of life, as well as the development of new and better drugs. It's an issue my father wanted me to promote. "Get the word out," he said.

 
At September 06, 2010 7:51 PM, Anonymous Kitty said...

Neurocritic,

Thanks for your informative post. Keep up the good work. I am sorry to hear about your father.

 
At September 06, 2010 8:22 PM, Anonymous Anonymous said...

Neurocritic,

Your post went through me as I read it. My condolences to your and your family.

Thank you for the work you do here.

Jon Newman

 
At September 06, 2010 9:30 PM, Blogger The Neurocritic said...

Kitty and Jon Newman,

Thank you very much. I appreciate it.

 
At September 06, 2010 10:15 PM, Anonymous Anonymous said...

Very, very sorry to hear about the loss of your father. Even though the loss stays with us, so do they - if that's any consolation at all.

FWIW, for some people there is significant anger (which I call rage) after the fact. If you find yourself furiously angry with not-exactly-innocent bystanders, chalk it up to that.

Best wishes and again, sorry for your loss.

 
At September 07, 2010 8:19 AM, Blogger jonathan said...

Sorry to hear about your dad's passing. You have a great blog ,though, keep up the good work.

 
At September 07, 2010 8:58 AM, Blogger Matthew J Brockwell said...

Dear Neurocritic, my condolences regarding the loss of your father. He would be very proud of you for writing this column, I am quite sure.

 
At September 07, 2010 2:47 PM, Anonymous Liza Ely said...

Thank you, Neurocritic, for your honest and thorough comments regarding palliative care. Like you, experiences with my elderly parents inspired me to become informed and to share with others how to experience greater peace at the inevitable end of life.

Sending you warm regards as you mourn the loss of your dad.

 
At September 09, 2010 9:48 PM, Blogger The Neurocritic said...

Thank you all for the condolences.

 
At September 10, 2010 7:50 AM, Anonymous Jennigma said...

I lost my grandmother to lung cancer when I was 8, and I would have done anything to ease the last months of her life. I still think about her every day, thirty odd years later.

I know there is nothing I could possibly say to make it easier for you to move through this time. But I wish, somehow, there was.

 
At September 14, 2010 9:28 AM, Blogger socialprimate said...

Neurocritic - I'm sorry to hear of your loss - I really appreciate your willingness to share your personal connection to this issue, and to unite your analytic and emotional perspectives.

 
At September 22, 2010 4:36 AM, Anonymous Jim Siegel said...

So sorry to read about the loss of your dad. Thank you for posting about the NEJM research study and the "death panel" canard. According to a new AP poll (http://bit.ly/c0RvnZ), a quarter of Americans still think the health care law includes "death panels". That ugly myth infuriates me personally and professionally, and every effort to debunk it is worthwhile. -- Jim Siegel from HealthCare Chaplaincy in New York

 
At September 22, 2010 5:29 AM, Blogger Rex Bickers said...

To Neurocritic:

At the risk of being misunderstood by those who will read my comments only superficially...

I am _happy_ for you... to read of your father's death. By your own description, he and those who cared about him most achieved success in "squaring the curve" - - i.e., maintaining a "normal life" for as long as possible during his terminal illness... then surviving for a _short_ period of time when the clinical consequences of mestastic lung cancer made it impossible to live that "normal life" further, as you, he and others perceive it.

Although you do not describe details of his final day(s)/week(s), I will assume the positive... that he died _where_ he wanted to be (or in the alternative, perhaps... did not know or care where he was), that his fears, pains, dyspnea and/or other discomforts were optimally relieved, and that he was surrounded by those who mattered most... at the _time_ that mattered most, to him.

Others imply that your "loss" occurred on September 6 when he stopped breathing. I cannot help believe that you knew the beginning of the loss a year earlier. You were always going to "lose" your father (or at least his breathing heart-beating body). The day that the "loss" reached "100 percent" is just barely a day to extend condolences to you - - only slightly more than any of the previous 365 days.

Once again, I am _happy_ for you and for others in your father's world... who have found the peace that comes from a strong and rational understanding of this final phase of your father's life.

Best wishes,

Rex Bickers, M.D.
neonatologist
Indiana

 

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