Building palliative and hospice care into the medical system earlier for patients with advanced cancers and other serious conditions is good, mentally and physically, for patients and families, and for a health system’s budget, said U.S. palliative care expert Dr. Thomas Smith.
“It turns out, telling people the truth doesn’t make them depressed,” said Dr. Smith, director of palliative medicine at Johns Hopkins Medical Institutions, even when the truth is that they are going to die. He presented last week at the Cayman Islands Healthcare Conference about how palliative care has been integrated across the Baltimore-based hospital system.
Presenting recent research on palliative and hospice care, that is, caring for a patient at the end of life, Dr. Smith talked about the importance of getting to know patients’ wishes before they become too sick to speak for themselves. This means knowing if someone wants to be kept alive with a feeding tube or CPR, making sure she or he has a will and that someone has been selected to make medical decisions on their behalf.
“Physicians are terrible at predicting what people want. Turns out, families are even worse,” Dr. Smith said.
He added, “I don’t care what your wishes are. I want to know so I can respect those wishes.”
The doctor showed conference goers an online form that the U.S. state of Maryland uses to make it easy for doctors and patients to make end-of-life decisions before they get sick.
Beyond the practical of breathing tubes and do-not-resuscitate orders, Dr. Smith said doctors should talk to patients about what their spirituality involves, and go into things like making sure there aren’t family issues like a brother or child they haven’t spoken to for years. “These are things you need to take care of while you’re well,” he said.
He pointed to research that showed that 90 percent of cancer patients want their medical team to know their spiritual needs during treatment.
“It’s very hard for us … to look someone in the eye and tell people they’re going to die,” he said. “If you can move that conversation up a couple months, people do things differently,” Dr. Smith explained, “[then] they’re much less likely to die in a hospital.”
Dr. Smith said research shows that it is easier for patients and family members to hear the bad news from a doctor they’ve never met before instead of the oncology team they’ve known for months or years. He said at Johns Hopkins, doctors trained in palliative care and end-of-life issues are embedded with the cancer center and other practices where patients regularly face fatal conditions.
He said he tells patients, “Tell your story while you still can.” He says talking about family and spirituality is important, and doctors can urge patients facing death to reconnect with family members or a church and do things they could regret never doing. For example, Dr. Smith said, he pushes young moms facing terminal cervical cancer to journal with their children.
He said that in his practice, a patient facing the end of her or his life, given enough time, should visit hospice facilities or meet with nurses and doctors who can provide home care during the final stage of life, assuring patients are comfortable and well cared for.
“Hospice makes people live longer,” Dr. Smith said. He presented a review of recent literature on outcomes from hospice care and most studies point to terminally ill patients living longer, from a few weeks to a couple months longer than those who die in a traditional hospital setting.
Palliative care overall also reduces costs to a health system, and Dr. Smith talked through research findings that show hospitals and healthcare systems spend less when patients opt to enter hospice care instead of spending their last days and weeks in a hospital.