End-of-Life Care

• Mr. Smith has come to see you for a two-day history of coughing, shortness of breath and chest pain. He has lost 20 pounds, cannot leave the house without help, and is depressed. The problem list on the front of his chart says "COPD, BPH, pneumonia, s/p CABG, CHF." He has been hospitalized three times in the last six months for pulmonary problems; sees you every month for hospital follow-up or new symptoms; and is getting worse. He and his wife seem to demand more care, time and reassurance as the months go by.
  
  
• Ms. Ray has pancreatic cancer diagnosed six months ago and has just been admitted to the hospital for vomiting and abdominal pain. She has been on various types and strengths of narcotics obtained through three different doctors, and is now moaning, unable to converse or answer questions. You are about to see her during morning hospital rounds, and have 15 minutes before you're late for clinic...
  
  
• The medical assistant has handed you a note saying that Mrs. Roberts needs to talk to you about her husband. He is demented and requires total care at baseline. For the last three days he hasn't been out of bed and has refused to eat. Mrs. Roberts wants to know what to do now.
  
  

Any of us who sees patients could have come up with a dozen scenarios just like these. Physicians know better than others what the end of life may look like, but many of us find ourselves ill-equipped to deal with the myriad issues that arise. We may be uncomfortable with our prognostic expertise; our ability to handle emotional or spiritual issues; our knowledge of pain and symptom management; or our ability to manage end-of-life discussions while we manage our schedules.

The need for expertise in end-of-life care is growing. The population is aging. The "compression of morbidity" has deferred the "inevitable" for many, but death is not thereby conquered. A disproportionate amount of health care dollars are spent during the last year of life.

When patients are finally helped onto a "comfort care" path, they are often mere days or weeks from death. The average length of stay in the typical hospice program is less than three weeks. The public's dismay over suffering and dignity at the end of life has been left unanswered by the health care system; all that some people know about such care is what they've read about physician-assisted suicide.

The EPEC curriculum was designed to address some of these issues. Funded by the Robert Wood Johnson Foundation, this curriculum was developed under the guidance of the American Medical Association, with the help of national leaders in end-of-life care. The two-day course is comprised of modules that focus on a particular area of interest - symptom control, advance care planning, communicating bad news, pain management, sudden illness, withholding and withdrawing treatment, to name a few. Each is taught by a separate instructor.

There are several plenary sessions which address some of the broader issues of culture, legal concerns, etc. Unlike more typical CME courses, the EPEC curriculum is relatively engaging and interactive. It is the most effective model for a continuing education curriculum that I know of.

Just as a two-day course in common heart problems won't make a cardiologist of you, the EPEC course won't turn you into an expert. But it is surprising how much a few days of thought and discussion can contribute towards making one a more confident and competent clinician.

There's not just one "problem" with dying - there are many, and they are profound and complex. We will all take care of patients who travel that road while under our care. We owe it to them, and to ourselves as both persons and professionals, to help them with competence, confidence and compassion.

Michael.Gunthermaher@kp.org