By 12 May
1. Watch the show, Being Mortal:
http://www.pbs.org/wgbh/pages/frontline/being-mortal/
2. What is the role of medicine? How should it address aging and dying?
Gawande says they are unfixable. Does that mean there is nothing to do
about them?
"By 17May"
Respond to at least 2 of your classmates' posts; develop the conversation by addressing one or more of the following:
1. What has surprised you about the content of the video or your classmates' response(s)?
2. What was the most optimistic part/message of the video?
Looking ahead: Next week (19 May) I am going to ask you to
1. Analyze
the show using our reading by Childress & Siegler. What models/metaphors describe most
end-of-life care in America today? Would it be better to use a
different metaphor? Explain.
I believe that the overall role of medicine is to improve ones health and increase life expectancy. When it comes to terminal illnesses, I believe the role of medicine is to treat the patient's symptoms to make them as comfortable as they can for the rest of their days. When Gawande says they are "unfixable" I don't think it means there is nothing to do about them. I think it means that there is no cure for them but comfort measure treatment is always an option. Medicines role in addressing aging and dying starts when the healthcare provider is still in school. Dying is a touchy subject and it takes a special person to be able to be realistic and honest with the patients.
ReplyDeleteI agree that dying is a touchy subject and even interveiwing the dr's that do this on a daily basis you could telll that it was still hard on them. The dr's get to know these patients and families and I would hope would grow to care about them just like they were part of the family. I cried through this whole movie. I can't imagaine having to tell patients on a daily basis that they don't have that much time left. I thought Gawande statement about being upset with the dr, when it came to his dad ,telling him that he could be up playing tennis the next week was very interesting. I feel like dr's do this sometimes so that they can bring hope to patients and their families but it is wrong.
DeleteJust to be clear, I cried through the whole film and most of the book, upon which the film is based. ;) I have taught biomedical ethics, which has always included a component of death & dying, since 1993. For the last 5-6 years I have taught a course focused on death & dying. I consult for hospice, too! so meaningful, but so emotional. Of course if it were my job, I wouldn't be effected quite the same way.
DeleteChanging our focus from healing to supportive care seems to be a difficult transition for many doctors to make. Maybe its the limited time they get to spend with patients. I think nurses get to spend more time getting to know people and pick up on the subtle changes that signify a change in the patient condition. We develop bonds , and when the time comes, I think this makes us better able to address the issue of death and dying. Nurses are by nature realists, whereas I think physicians sometime hold out for that possibility that things may still turn around.
DeleteI think the time that nurses spend with their patients may give us the ability to recognize those subtle changes in patients. You can see it in their decision not to continue with testing, or hear it in the things they may say to visitors as if they are giving their family and friends some insight into the way they see things unfolding. We had a patient just this past week as his children to plan to spend the afternoon with him as soon as he goes home so that he can tell them things that they need to know and do when he is gone. It is heart breaking and the physician has not been the one to encourage this. The patient has realized this on his own.
DeleteI agree that is was wrong for the MD to give a good prognosis to the father. I do see that it is hard for the MD as well because in medicine we have been educated to preserve life at all cost. I feel it is a fine line to walk because you do not want to lose hope.
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ReplyDeleteI beliveve that the role of medicine in terminal illness is to help or guide the patient and family to make the right decisions. I think that most dr's do try to treat the illness when the patient is first diagnosis no matter what it is. Most dr's want to fix things. I believe as the patient condition worsens they should sit down with the patient and family and discuss options.I think the film did a great job in showing the struggles that the dr's themselves have with talking to patients and families. I also liked that when they did get to the point of having the end of life discussion they had someone there to help them discuss the options. Medicine is not a fix all. We can not stop aging or dying. We can only delay it for a short time.
ReplyDeleteI too was surprised that there was someone else in the room with the Dr. to help discuss the options available. That was very helpful for the Dr. and the family. I thought the most optimistic part of the video was the allowing of the Patient to choose how he wanted to die, death with dignity.
DeleteI agree with you fully. I think having an extra person in the room, maybe a palliative care nurse, while the patient is receiving bad nurse is the best for the patients. I have seen so patients on our unit get the news of cancer and have to wait hours or even a day to talk with a oncology doctor or a palliative care nurse.
DeleteComfort care is very important for someone with a terminal illness. But everyone's definition of comfort care may not be the same. For example when a physician tells someone they can have comfort foods that does not mean the you should feed someone when they are clearly aspirating and then require suctioning after they have eaten and aspirated. Or that you encourage someone to eat even though they are nauseated to the point the you vomit and then require medication for nausea and pain from vomiting.
DeleteI will say I have been in the room several times with physicians as an ER nurse to discuss how a code was progressing. It was a positive situation for the family, even thought the patient died. I felt my role was to monitor the family and their emotions during the discussion. I clarified things after the MD had left the room and gave support during a hard time. The physician was also able to get back to the patient quicker knowing someone would be with the family.
DeleteGawande statement about the patient being “unfixable” is a good example about how medicine primary focus on treatment and curing the illness. Often Physicians feel as that they are at fault for the outcome or prognosis of the patient. Doctors may struggle to support a family when they are not prepared for their own emotional response that the death of a patient can elicit. This may be especially difficult for doctors who are parents of young children. It is essential that physician’s receive therapeutic communication training about the bereavement and dying process.
ReplyDeleteWhat surprised me about the video was how candid the Patients and their families were with the interview video process. It felt like we were a fly on the wall watching as a third party. I would hope that therapeutic communication training would be integrated into the education process of becoming a doctor. That was a good observation Jodi.
DeleteThis video was very emotional as is any end of life topic with Patients and their families. I thought the role of medicine was well demonstrated in the examples given. To me the role of medicine is working together as a health care team, family members and the Patient to find out and implement the best health options or outcomes available for primarily the Patient and then the family. It is the nature of life to hopefully grow old and then die. I think this is a very positive way for medicine to approach this topic. The physical act of the aging and the dying process is not fixable but it can be made doable with better understanding and empathy of the process. This is done with education and compassion, relieving fears, drawing in those you love and fulfilling those emotional needs and goals. It seems that once the fear is conquered the rest falls into place.
ReplyDeleteThis video surprised me in that they spent a great deal of time talking with the patients and families in regards to options available or to let them know they had reached the end. They gave them all the options and let them choose which route they wanted to take for their treatments. I appreciated that they gave them a lot of input and let them sort of assume control of their care and were there for guidance.
DeleteThese physicians did spend alot of time with patients. I think this is how it should be. Patients are scared of the unknown and spending time answering questions and being there for them emotionally is so important.
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ReplyDeleteIt is always emotional and tearful when talking to patients and families about death and dying. And yes, it is okay to cry with them.
The medical field should be well equipped to address aging and dying, We have access to almost unlimited resources and information and are well aware of the dying process, but still have much difficulty discussing this topic with patient's and families. I find this to be more true with doctors than nurses. I think this is because spend more time at the bedside. I find about one-half of the physicians I work with listen to what the bedside nurse has to say and values their opinion and feedback regarding comfort and dying. The other half want to try to save the patient until there is a sharp decline and then will agree to more aggressive comfort measures. There is something that can be done, but it would mean the entire healthcare team would need to come together and agree on a plan of care that is well suited for the patient and family. The patient and family should be involved in the process and given opportunity to ask questions and voice concerns. I have personally cared for many end of life patients and they, and their loved ones, need us to be there for questions and a shoulder to lean on. They look to medical professionals for guidance and answers.
I could not agree more. Gawande in the video even says that medical schools do not spend enough time on this subject of death and dying. I also think families need to be more open about the subject even before being faced with a terminal illness.
DeleteThis was so heartbreaking to watch loved ones go through the dying process. I believe the role of medicine is to be upfront and honest throughout the whole process, while being supportive of them and their decisions at the same time. It was interesting that most Dr's had a hard time telling the families the real truth about how long their loved ones had left or that they could try more treatments for a better outcome, when they knew that was not the case. Most Dr's have a hard time admitting they cannot fix them. That does not mean there is nothing to do, because most of them still have several months to a few years to live once diagnosed. The Dr's can make the most out of this time and help them to have optimal treatment and help alleviate their symptoms. Even though they aren't fixing or curing them, this is still being a compassionate support system to them. I believe they should address aging and dying with dignity and take that into consideration when talking with families who have a loved one with terminal illness. The young can possibly withstand more treatment and may respond better than the elderly, making each situation different and the treatments options different for each family.
ReplyDeleteMaking the most of the time left is so important. Like the woman in the video she wanted to take her grand daughter to Walt Disney. If these conversations take place soon enough before patients get too sick and the doctors know the goals of the patients they can work together so that their last wishes can be accomplished.
DeleteDeath and dying is a difficult subject for healthcare professionals to address with patients. It does feel like, as was stated in the movie, that if you begin to discuss the end of life, that you have given up on the patient's chances at a cure or your ability to fix them. I think the role of medicine is of course to treat, cure, and prevent, however medicine is holistic in the sense that we should care for the human body as well as the human spirit. When issues face us regarding aging and dying we must attack the conversation as we would if we were treating any other problem. We should be upfront and honest about the death and dying process and understand the patient's and family's goals throughout the process. Medicine should always prioritize itself on the comfort of the patient. Ultimately, there is nothing to be done about the aging process, but in terms of dying, being a support system, being honest, and by supplying a means of comfort to a human being is the most that can be asked.
ReplyDeleteI agree death and dying is so hard to talk about. I see this all the time on my unit when patients our first given test results that state they have cancer. To them the word cancer means death. However, most of the time the first thing that is dicuss is treatment. I feel that we as haelth givers should discuss death and the dying process. If patients hear it up front then it could be talked about more freely.
DeleteBeing a Hospice nurse I still encounter patients and families that have a difficult time with accepting the dying process.
DeleteI think only rarely do physicians address death and dying with their patients. The role of medicine for the aging population remains treatment and “fixing” the problem. An aging patient can only be fixed for so long. It would be beneficial for conversations to take place regarding goals for their life and fears they may have of growing old and death. This is such a difficult topic to discuss but these discussions give the benefit of knowing exactly what the person wants out of life instead of asking in the midst of a crisis. These conversations can become the guidepost of how to move forward and live life! Physicians have training to “fix” the problem, not tell someone there is no solution. This was a very moving video, I could feel the compassion these physicians have for their patients. A comment that stood out was the equal importance of the technique with which the message was delivered as well as the skill of listening and sometimes you need to sit in silence to allow the time needed for processing what was stated.
ReplyDeleteI agree Cindy physicians should address death and dying with their patients. It would make it easier to discuss when the end is near. Everything can not be fixed and aging is just a part of life.
DeleteI also believe that death and the dying process should be discussed with patients even if it is a hard subject to talk about. I think that primary care doctors should begin this conversation with their patients before a terminal illness takes place so the patient and doctor already have an open communication set in place for this subject.
DeleteYESSS!!! Goals- that's what if fundamentally missing from most of our conversations - especially with our elderly patients . They get admitted , and ultimately we decide what WE want for them, not want they want form their hospitalization. We may be thinking about that elevated BNP or positive troponin, but they are usually thinking about the cat they left at home , or the grandkids that aren't allowed to visit. We need to stop and consider what is most important to the patient.
DeleteI love the idea of goals too, what a great idea to talk to patients about this before it gets too late in the game.
DeleteI love the idea of goals too, what a great idea to talk to patients about this before it gets too late in the game.
DeleteThis show just amazed me. It was so emotional. Since Ft Thomas closed their inpatient hospice unit, the patients that do not want to be transferred to Edgewood but still wish to have inpatient hospice care are moved to our medical surgical floor so we get to see end of life first hand. I have never wanted to work in hospice care but after caring for many hospice patients on our unit I have really come to enjoy it. It is an emotional roller coaster every time I take care of one of the patient's and their families. So of the most touching times I have at work is just to sit next to a end of life patient's bed and hold their hand so they will not have to be alone.
ReplyDeleteI believe that the purpose of medicine is to cure the curable, but not make the treatment stand in front of what the patients wants. If a patient is unable to be cured the doctors need to make sure the patient and family understands this, and not give false hope. As the movie shows sometimes the treatment can shorten a persons life instead of healing. The movie also talks about prolonging life but not the quality of life.
I enjoy the inpatient hospice patients that I have taken care of as well. Every time I have had a special experience with great patients and families.
DeleteI agree as well. I truly enjoyed caring for hospice patients. I feel it is so rewarding caring for these patients that are in such fragile state.
DeleteElizabeth I think a wonderful quality of most nurses is the ability to do what is needed, even if what is needed is to stop and be there for our patients. At those moments, you are satisfying the greatest need for that patient.
DeleteThe Frontline video showed and discuss so many great topics to explore. I have to say I cried with the families dealing with their love ones death. The strengh that the patients had and family support was refreshing to see. I wish I could be that strong talking with patients at work. This did give me some insight on how to address dying and death. The emotional roller coaster is so hard to deal with. The ups and downs of what to do for treatment or not to treat. Curing is what we do but sometimes steping back and letting the patient explore what they really want is the best thing to do. What do they want in the end. Lets open the can of worms in the beginning so that everyone is on the same page. One thing that poped out in the video is when Bill (the pt with brain ca) stated he was tried of getting bad news in a nice way. I feel we are so geared and groomed to putting on a smile we forget to turn it off when the situation is bad.
ReplyDeleteI remember Bill well also, Shirley. And his body language spoke volumes. You could see the anger during that visit. But he did give the Dr. a hug later. I wonder if the anger he we describing was the anger he had towards the disease but it came out directed at the physician and her "nice" delivery of bad news. Also, I would be curious to know if those physicians have a higher rate of turnover or burn out than other specialties.
DeleteDeath and dying is such a emotional topic. This video was so inspiring to me in regards to how the physicians spent time discussing this with their patients. I can't imagine how hard this would be to tell someone that there is nothing more that can be done. Physicians need to be totally honest with patients/families so they don't get their hopes up. Patients need to be informed of options they have such as pallative care, home hospice vs inpatient hospice, and respite care for the family members caring for them. They also need to understand quality of life vs quanity of life.
ReplyDeleteEnd of life is a very sensitive topic. Everyone deserves to be informed and to be given all options available to them. Palliative care is very under used and I think a lot of patients would benefit from a consult since not everyone is ready to chose hospice.
DeleteTricia, I agree about death being such an emotional topic. I do however think letting a patient know medical treatment may no longer stop the progression of disease, may not signify doing nothing. I believe as health care providers we are egocentric, myself at the top of the list with that quality. We feel if we have a goal and don't reach it, we are not of service to the patient. When a patient is allowed to know their life is nearing it's end they now have an opportunity to focus on what they want to do. As nurses it still gives us the privilege to serve and assist.
DeleteEvery day I see physicians who fail to discuss the topic of death and dying with their patients even when the facts are laid before them that it is inevitable. I thinks as healers it is ingrained in them that you remain hopeful for the patient and families. All too often, we wait until it is essentially too late to begin speaking of the dying process. I think as caregivers we have a responsibility to speak frankly and openly with those under our care and should consider it a part of holistic care. Death is a natural process , avoiding it is a disservice in caring for the whole patient.
ReplyDeleteI agree that we wait too long to bring up the subject with families, many of us know days ahead that the end is near but remain silent. It is surprising to me that even the Dr's have a hard time bringing this subject up to the families and try to ride it out as long as possible. It is so optimistic though to know most doctors are caring and supportive and are in this profession for the right reasons.
DeleteI also agree I don't see enough nurses sitting at the bedside discussing death and dying to the patients if this is where things seem to be going. Doctors are caring for the patients just as much as the nurses and they need to be there as well to educate and inform the patient of what should be expected.
DeleteI also feel that death and dying is a very hard subject for families. I feel that this is something that should be talked about before being faced with a tragic event. I feel that overall nurses do a good job at being supportive and caring towards thier patients that may be dying of an illness. This is what nurses are made for. I think that not all doctors have this same quality. Some doctors want to fix things like most men in the world, and when they can not doctors seem to go to comfort measures. In these situations I feel that it is nice for doctors to be able to sit at the bedside and hold the patients hand and just talk. This shows caring in the best way. Spending time with the patient and listening to them. Death is inevitable for everyone and should be an open topic not one that we all hide from. A lot of decisions need to be made at the time of dying and having a plan makes this process slightly less stressful for the people involved. In the video Gawande talks about school not teaching about death and dying enough to the nursing students and I agree. This needs to be touched on more thoroughly to make us better more prepared nurses.
ReplyDeleteI agree with the role nurses play in these situations are very important. I found it surprising and slightly awkward how many of the serious conversations that took place in the episode with the physicians standing. Sitting gives the perception that you have time for them and helps open the door for them to communicate back.
DeleteThe role of medicine is to do the best thing possible for the patient. Being honest and open with the patient and their support system. Collaborate with them to set reasonable, personal goals. Saying that these patients are unfixable is kind of degrading. They are humans, not electronics or something disposable. Sometimes the goal is to provide treatment for a cure, sometimes the goal is help the patient pass away with dignity in comfort. Having a discussion about mortality that is within sight can be a very hard discussion to have. But, helping a patient come to acceptance with the inevitable and being a part of their passing and providing comfort to them and their families can be extremely rewarding.
ReplyDeleteI believe that medicine is used to treat symptoms of whatever disease process a patient is experiencing. Sometimes medicine can cure, but not always. Aging and dying are unfixable. There is no way to prevent aging and when a person has an illness and has already exhausted all available treatment then dying becomes unfixable too.
ReplyDeleteConversations of death, dying and a patients wishes has to be the hardest part of a physicians job. I find that most try to avoid it until it's too late. Nurses spend the most time with patients and I find that we begin those conversations and the physicians will address it once we inform them of the conversations that have taken place already. I think people deserve the right to die peacefully and that can't happen when they are uninformed of their prognosis.
Death and dying is a subject that many do not want to discuss. We are not designed to last forever. God gave man the knowledge and tools to be able to treat disease and yes even cure but he did not intend for man to live forever.
ReplyDeleteSome times I feel most people avoid talking about death and dying because of the fear of the unknown.
Physicians need to address the issue at hand, but they are not always comfortable with it. I have also seen that when patients are in the hospital and they usually are seen by a physician who really doesn't know them except what they are reading in a chart. That make death and dying a very uncomfortable and difficult conversation to have.
Even when someone has made the decision to become a hospice patient they still struggle with death and dying. Again the fear of the unknown.
I agree Donna, many physicians do not know their patients. I am not sure if or where any blame lies. There are physicians who are able to know their patients. Not only oncologist, but I have seen it with a wide range of disciplines. I think it can empower a patient and gives them a desire to want to follow guidelines, medicine regimes and other recommendations given by the physician.
DeleteAt the heart of medicine is the desire to do good. I was pleased to see the admission by Dr. Gawande that he had very little experience and or training on dealing with patients who are actively dying. I have to believe that few if any of us are born with that kind of compassion to be able to deliver such harsh truths without crushing the spirit of the patient when that spirit may be the healthiest part of the whole person. I also believe most of us are capable of learning. Dr. Gawande seemed to have a genuine desire to learn how to have those conversations in an effective and compassionate manner. I was surprised by his honesty in talking with the husband of the young women who died shortly after giving birth.
ReplyDeleteI feel the best way to learn this skill is through observation and practice. If the conversations start with an understanding of the disease process, available treatments, both well established and experimental, and are based in true compassion and empathy, they can be productive. Regardless of how difficult those discussion become, they are necessary for the good of the patient.
What is the role of medicine in relation to the dying process and aging? I believe that death and dying are as important as preserving life. There is only one certainty in life and that is death but often times it is left out of the patients plan of care. Patients should be given an honest realistic prognosis so they can decide how to live during their final days.
ReplyDeleteMany times as noted in the documentary Being Mortal, health care workers look at a situation and try to avoid the conversation of death or that it is a probable outcome. The fact of the matter is no one wants to die but it happens to everyone. I appreciated the role of the palliative care MD in the documentary. I felt she would have been helpful to consult in the case of the pregnant woman. The husband felt her last days were not spent well. He stated that she felt more ill than she should have due to the aggressive treatment implanted to save her life. I agree there is a time for aggressive treatment but I also believe a patient needs to be informed of all avenues of care.
How the dying process is approached my physicians and nurses is important to patients. Death is a natural process that is often discussed later with referrals to hospice given later than they should be. hospice is a wonderful, compassionate part of medicine that guides the patient and family through the dying process.
While working as a nurse I had a patient who was hospitalized with complication of COPD. He had had three inpatient stays in two months. After the second hospital stay I encouraged the patient to have an appointment with a hospice nurse. The patient declined stating that his physician said he had several years of life left and it was not needed. While seeing the patient on a weekly basis not only did I notice a physical decline but also a spiritual decline with him. Three weeks after my initial encouragement for hospice the patient was admitted to the ICU after a 3 day failed rehab stay. The patient was on bipap and made the decision to be taken off and died in the hospital with his daughter but none of his other family at his side due to the rapid nature of his decision. I feel that if hospice was involved the transition to death would have been more beneficial to the family and the patient.