Merry Christmas Message

In our little corner of the world, Christmas morning has arrived with a little snow on the ground and a definite nip in the air. We have had a wonderful year on Prince Edward Island, and with the arrival of our second Christmas, we have come to appreciate and enjoy the warmth of our small town even more. The island has allowed us to slow the speed of our lives, given us the chance to look around, and reminded us of the joys of daily living. It has given us the chance to learn who makes our food and buy from them directly. It has given the opportunity to see the needs of others and help. It has reminded us of the spirit of community and encouraged our inclusion. It has released us from the bonds of time by asking us to sit for an hour when we drop by for a visit. In short, our little corner of the world has helped us return to the values and ideals that we believe in our core. It is our sincere hope for each of you, that this opportunity to return, refresh and re-energize comes you way, and in so doing renews the joys of your life and living.
Merry Christmas to you all….…..Gil and Nancy

Do the right thing.......

There has been a profound change in my practice since I left Texas, hospice and palliative care have become a very significant portion of my practice. This change has left me with deep questions regarding the practice of medicine, and has left me considering the obligation to ‘Do the right thing’.

When the focus of your practice is to diagnose and treat with an eye toward recovery, the right thing is a bit more obvious. Your charge is to figure out what is ailing the patient and make it right as quickly as you can with the least amount of harm to the patient. It is a balancing act between beneficence and harm. Harm comes in many forms, cost (for unnecessary tests), radiation (CT scans), pain (invasive tests), misdiagnosis (finding the wrong thing, or finding something incidentally that leads you on a goose chase), and side effects (every treatment has a risk). You are always balancing this against the good you are working to accomplish, asking yourself if these things are really needed in order to help the patient heal.

How does this change when your role is to help someone have a ‘good death’? The purpose is no longer recovery, but to comfort, and that changes the equation. Comfort care seems very straight forward when presented as such. You provide care to the patient that brings them comfort, relieves their suffering, and makes them at ease. At first glance this does not appear to be that difficult, and in many cases it is not. The symptoms that the patients have are such that they can be managed without any direct risk to their well being and care is provided with a minimum of risk.

When pain is a significant symptom, then the situation changes, the risks increase and the chance of harm is ever present. Most patients fear the suffering associated with pain. Pain is a great teacher; it is there to keep us alive. Pain is there to make us release the hot object, struggle against the trap, fight against the darkness. Pain is an intrinsic element of humanity, it is the great equalizer. The treatment of pain is a first order priority in the care of the hospice patient. In the minds of many, the control of pain is essential to a ‘good death’. The unfortunate risk involved in the treatment of pain is the hastening of death. The medications that are used to treat pain, narcotics primarily, all have side effects that include depression of the respiratory system, that is, they slow your breathing, sometimes fatally. The inclusion of anti-anxiety medications often makes the respiratory problem worse, and unfortunately many people have a great deal of anxiety as they approach death.

How do you balance this equation, providing for the comfort and care, but avoiding the ultimate harm? It is easier when the patient looks you in the eye and tells you what to do “I do not want to suffer, and I do not care if the medicine makes me die sooner”. But what of the patient who asks you to “Do what you think is best”. What is best? How can you know? What is best for this patient? Do you work to relieve the suffering knowing you are shortening their life? If that time is but a few hours you might not worry, but what if it is a few days, a few weeks? What if the treatment you provide gives complications that increase the suffering of the family? How do you balance these equations?

Currently the province of Quebec is having a vigorous debate on euthanasia ( CBC, Forum, Government). This debate is also happening in Europe on a larger scale (BBC , Research Article) and in the United States as well (Grid on Legal Efforts by state, Annals of Internal Medicine ). I suspect this debate will continue throughout my lifetime as it has throughout the lives of others. However, my question for now remeains, when does the provision of care and relief of suffering cross that line, and how will I know if I am doing the right thing?