ASCOPost.com | NOVEMBER 15, 2011
PAGE 47
Expert’s Corner Palliative Care
A Conversation with Judith Redwing Keyssar, RN Lessening patients’ suffering at the end of life By Jo Cavallo
Judith Redwing Keyssar, RN
T
a society unable to come to terms with our own mortality? In our American culture today, the concept of impermanence is not one we can relate to easily. In other cultures, the fact that birth and death are part of the cycle of life and that we are only here briefly is much more accepted. Also, until the early- to mid-20th century, families took care of their loved ones who were dying at home, and death was more a part of everyday life. Today, people don’t see death in their world.
he number of patients seeking Slow Acceptance of Hospice hospice and palliative care has Do recent medical advances, especialgrown significantly since 1974, when ly in life-threatening diseases like cancer, the NCI funded the first hospice facontribute to making it more difficult for cility in Branford, Connecticut. Nevpatients—and physicians—to consider ertheless, according to the National hospice care? Center for Health Statistics, 85% I think that’s absolutely true. I read of Americans still die in hospitals an article that said new treatments for or nursing homes. This prevalence cancer have delayed hospice referrals continues despite research from the because there is the hope that a new National Hospice Foundation showclinical trial or another treatment ing that nearly 80% of patients would might make a difference. And yet ofprefer to die in their homes, free of ten in the expectation and delivery pain and surrounded by their loved of more treatment, quality of life sufones. fers. How many times have we seen For more than 2 decades, Judith people being given chemotherapy up Redwing Keyssar, RN, has helped until a week or two before they die? dying patients maintain their qualWhen I hear a physician say a patient ity of life as they make the transition wants to keep refrom life to death. ceiving treatment, The Director of Hospice care is not it’s often because the Palliative and that’s what the End-of-Life Care just about facilitating a health-care proProgram at Sepeaceful and pain-free vider is suggesting niors at Home, a to the patient. If division of Jewish death. It’s also about life treatment is being Family and Chiland assisting patients in offered, patients dren’s Services of San Francisco, and having a high quality of life think there must be a good reason author of Last Acts for as long as possible. and that there of Kindness: Lesmust be hope that sons for the Living it’s going to make from the Bedsides them better. of the Dying (CreateSpace, 2010; But there comes a turning point www.lastactsofkindness.com), Keyswhen continuing treatment is futile sar talked with The ASCO Post about and sacrifices the patient’s quality of how oncologists and other medical life. Maybe the treatment will allow a professionals can use palliative care patient to stay alive an extra week or approaches to help ease the suffering month, but is that extra time going to of their terminally ill patients. give him the kind of quality of life he The Final Taboo would really appreciate? You say in your book that death is the Most patients aren’t referred to final taboo in our culture. Why are we as hospice care until the last month or
EXPERT POINT OF VIEW By Diane Meier, MD, FACP Director, Center to Advance Palliative Care and Hertzberg Palliative Care Institute Mount Sinai School of Medicine New York
I
n her interview with The ASCO Post, Judith Redwing Keyssar, RN, sheds light on easing the suffering of patients facing the end of life. Although what she says is appropriate for patients who are clearly dying, I would emphasize that palliative care is also pertinent to patients who are not terminally ill. An increasing body of evidence shows that delivering palliative care at the point of diagnosis of a serious illness not only improves quality of life for both patient and family, but also extends life. It does this by, among other things, helping patients avoid risky or harmful settings or unnecessary treatments. The article speaks to an important but very narrow population of those who are dying imminently. However, it is vital for oncologists to be reminded of the added value of offering palliative care at the same time that diseasedirected treatment is initiated for their cancer patients.
■
Disclosure: Dr. Meier reported no potential conflicts of interest.
two of their life and sometimes not until the last few days of their life. That is partly because health-care professionals still have a hard time accepting the fact that their patient is going to die, and they are not comfortable having that conversation with the patient. However, greater acceptance of palliative care approaches and the advent of palliative care physicians and specialty teams in hospitals are starting to make a big difference in helping initiate end-of-life care conversations with terminal patients. We have to acknowledge that having these conversations is as important to the patient’s clinical care as knowing how to do surgery to eliminate the cancer from the patient’s body.
Fear of Death Why are people so afraid of dying? It’s like any other unknown we have to deal with. It’s scary because even though we’re all going to experience death and dying, we don’t talk openly about it and we don’t know what the process looks like. While hospice and palliative care practices have become more well known over the past 15 years, many people still don’t know the details of what
happens when a person dies so, of course, the concept is very scary. We have to get better at talking openly about death and dying and giving people more information so that it’s not so frightening. Death is a normal process, and we don’t need to be afraid of it.
Making the Transition How can oncologists help their patients make the transition from active treatment to end-of-life care? It’s difficult because often there isn’t enough time in a typical office visit to address all the clinical issues and then discuss end-of-life care if treatment fails. It’s important to reassure patients that if conventional treatment fails, the palliative or hospice team will make sure that their life will be free from suffering and as high quality as possible and to dispel the myth that a referral to hospice care means death is imminent. Hospice care is not just about facilitating a peaceful and pain-free death. It’s also about life and assisting patients in having a high quality of life for as long as possible.
■
Disclosure: Ms. Keyssar reported no potential conflicts of interest.