A ‘STAT’ Palliative Care Consult: Cognitive Dissonance Meets Cognitive Ignorance

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Original story posted on: January 24, 2018

Palliative care is medical care just as are other medical specialties. 

I was in the midst of a perfectly comfortable morning, my computer was working, my coffee was hot, and my desk was uncluttered. My brain was quietly marinating in caffeine one minute and then suddenly it was discomforted because in the next minute we received a request for a STAT Palliative Care Consult. A STAT Palliative Care consult is disquieting because ‘STAT’ is a dissonant adjective for the compound noun, ‘Palliative Care.’

‘STAT’ is the medical abbreviation for the Latin adverb ‘statim’ meaning ‘immediately’. ‘STAT’ orders always imply the necessity of an immediate response to an emergency: an inadequate blood pressure, an erratic hear rate, a falling oxygen level – all potentially life threatening. ‘Palliative’ derives from the Latin verb ‘palliare’ meaning ‘to cloak’. Palliative Care literally means to cover over with care – to alleviate without curing. ‘STAT Palliative Care’ is a dissonant expression in any language. Palliative Care is a process, not a single act but the consult was asking just that: an immediate single act.

In our ER was an elderly gentleman moribund from not one but two widely metastatic cancers. His life was rapidly fading away piece by piece – hypotensive, hypoxic, lethargic. By his side was an elderly gentlewoman overcome by a growing grief. Her husband of 50-some years was slipping from her grasp minute by minute. She was overwrought - what was happening, would he die, would their children arrive in time?

The ER doctor diagnosed the gentleman as a dying patient in the final act of a cancerous play in which the many metastatic actors were hurriedly dragging the living one offstage for the final curtain call. But there was no script for the final act –he had no living will, he did not have a POLST form, he was still a FULL CODE. No one had told this couple they were in the last act, no one had discussed or prepared them for the ending. So the ER doctor improvised, he called for new actors and he wanted them on stage immediately. He called for a STAT Palliative Care consult.

The final act was mercifully short. Yes, she knew her husband was dying in front of her eyes. No, he didn’t want heroic care under any circumstances. Yes, she wanted him comfortable above all else. No, she didn’t want to wait for their children but prayed they would arrive in time. Yes, the morphine was started. No, the children didn’t arrive before he died. No, she couldn’t comprehend what had just happened. Yes, she was relieved his suffering was over. No, she was not relieved her husband of so many years was dead. Then she tearfully spoke the closing lines of this cancer play, “Why didn’t somebody tell us?” Words far too often heard - more pleading than questioning.

Indeed, why hadn’t they been told? Well, in many places they would have been told. In many places his death wouldn’t have been a surprise ending. In many places he would have not died among caring strangers in a hospital but with loving family, perhaps, at home. In many places the patient and the family would have suffered less – much less.

But not in all places and this is where dissonance meets ignorance. In the 21st century, no patient with advanced Congestive Heart Failure would be denied Cardiology care.  This would not be acceptable medical practice anywhere in America. But some patients suffering despite curative treatments for heart failure or a myriad of other aliments are denied Palliative Care. This seems to be an acceptable lack of care in some places, worst yet, it is tolerated. While ignorance about Cardiology would be deemed unacceptable, lack of knowledge of Palliative Care seemingly can be the community standard. Relieving unnecessary suffering is no less a clinical responsibility than relieving pulmonary edema. Palliative Care is medical care just as is Cardiology and the host of other medical specialties are. Ignoring unnecessary suffering in patients mastered by their disease like the ignoring desperate dyspnea in patients overcome by CHF. But the problem may be worse than ignorance; it may be indifference.

There seems to be an insouciant clinical myopia that clearly sees the physical symptoms of disease but is unable to focus in on the suffering the disease is causing – the pain, the loss of control, the anguish. A doctor cannot help the sufferings they do not see. However, it is the obligation of a physician to help the patient and their loved ones see of the trajectory of the disease - where their disease is taking them and the end of the disease that will be the end of them. Some doctors seemingly have an apathetic nearsightedness that only sees the problems in their clinical neighborhood – the edema in the ankles, the wheezes in the lungs or the size of the cancer. They see or only will look at the disease but not the patient whose body the disease is ravaging. They are not uncaring but something worse: they are blind to the patient’s suffering.

Every doctor has the instinctive reflex to immediately staunch the hemorrhage of a bleeding patient. Regrettably, there seems not to be an analogous instinct to staunch suffering of an anguishing patient. Why? Is it a lack of education, a lack of expectation, and a lack of empathy?  Why the discomfort to discuss dying? A menagerie of workshops, symposia, commissions, and articles have explored this problem. Some have supposed that educational deficiencies leave physicians feeling unprepared and lacking confidence to discuss end of life issues. Others focused on that many physicians have an abiding reluctance to accept that treatment cannot be in the patient’s best interest. Many regard death as a failing. The most concerning conclusion is that some doctors just fail recognize the terminal stage of diseases; they are just ignorant of it.

There is, perhaps, another matter that the insightful physician-author Abraham Verghese put his literary finger on in two simple sentences: “In Medicine, as in writing, there are no short cuts. You need stamina.” But stamina is increasingly in short supply in clinical medicine. It being is sapped away by the stresses of electronic, legal, financial, administrative, and insurance worries.  There is a burgeoning realization that medicine can be a cruel to its practitioners.

Delivering bad news can be brutal to the tellers just as it is to the hearers. So many physicians consciously or otherwise seek to avoid what they feel to be brutalizing encounters but in doing so they brutalize the suffering patient even more.

The answer isn’t to shun what seems like yet one more emotional trauma – the dealing with the suffering of others. It is not the avoidance but the acceptance of that relieving suffering is compassionate, merciful, and rewarding for both the doctor and the patient. Not knowing this is the ignorance that results in STAT Palliative Care consults – not knowing that relieving the suffering of patients fulfills a physician’s humanity. The real dissonance is that it withers a doctor’s clinical heart not to unburden patient from a suffering that is in their power to relieve.

We live in a medical world where many patients continue to endure insufferable disease states. There is Palliative Care that could comfort them but it is ignored. All of us – the healers and the afflicted, the sick and the well, the insurer and the administrator – need to advocate for more and earlier Palliative Care.

Some might think that STAT Palliative Care is better late than never. It is not because it is no longer Palliative Care, because the time for Palliative Care is gone and missed, just like the elderly gentleman in our ER. 

Michael A. Salvatore, MD, FACP

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

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