EDITORIAL: Doctors, patients should discuss end-of-life issues

We need to talk about the last months of life.

An illuminating recent study found that patients with terminal lung cancer treated in conventional ways got an unexpected bonus if, shortly after diagnosis, they also got care geared to help them live as well as possible, rather than as long as possible.

They not only experienced less pain, discomfort and depression, they actually lived longer than comparable patients who received only the usual cancer treatment. And they got those extra months of life even though many chose to forego some aggressive, expensive treatments. This study, and other accumulating evidence, should be the wake-up call we need to reopen a difficult conversation about end-of-life medical care.

In the long slog to health care reform, no subject was more cravenly exploited for political advantage. The ominous term "death panels" ended all reasonable debate. But we can't just leave it at that. Talking about dying is tough - but thinking, talking and planning for the inevitable should make death a little easier, not to mention less costly.

The quintessentially American way of dying is to fight it as long as medically possible. The result is often needless suffering, anguish and expense. About $125 billion of the $497 billion Medicare will spend this year will go for care in the last year of life, much of it ultimately futile.

Changing that doesn't have to mean rationing medical care by denying treatment to save money. Nobody wants to speed granny's demise. But we should make sure that the terminally ill have the information they need to weigh different approaches to care in their final months, and what those options mean for the quality of their remaining time.

Some will choose aggressive, pull-out-the-stops treatment to grasp every day possible. That choice should be respected. It's how many people die now: in hospitals, enduring procedures and surgeries, often on respirators or other machines, oblivious or in discomfort.

The goal of that approach is noble - to prolong life, even if it's a painful existence for someone with no realistic chance of recovery. There's no way to put a price on hope.

But Americans must come to accept that sometimes, there is no cure. That's a broad cultural shift that will take effort and time to achieve. At this point, instead, as Dr. Dana Lustbader, a critical care physician who runs the palliative care unit at North Shore University Hospital, says, "We're frequently prolonging dying."

Palliative care offers an alternative - and it's not a choice between treatment and doing nothing. The difference is in the goal of treatment.

If what's important to a terminally ill person is to be free of pain and discomfort - like nausea or shortness of breath - and to remain lucid so he or she can share precious time with loved ones, doctors should know that and help patients to achieve those aims.

That's what palliative care does. And helping dying people live as fully as they can is every bit as noble as helping them live as long as they can.

Then there's that bonus found in the study reported this month in the New England Journal of Medicine. The three-year study involved 151 patients with an aggressive, metastatic lung cancer. The illness usually results in death less than a year after diagnosis - so it is significant that patients in the study who got palliative care lived two to three months longer.

Researchers didn't determine why those who got palliative care integrated with standard treatment lived longer, despite opting for less chemotherapy, fewer emergency room visits and more do-not-resuscitate orders. They speculated that dealing with less pain and discomfort warded off depression, which is known to shorten life. And fewer hospitalizations means less exposure to infections that are dangerous for the gravely ill.

There is even anecdotal evidence that just talking with patients about their end-of-life goals, or having them complete a questionnaire on the subject, can reduce hospital stays and cut spending for futile treatments.

The New York Palliative Care Information Act, signed by Gov. David A. Paterson this month, could test that notion. It requires that doctors or other caregivers discuss end-of-life options with terminally ill patients. It will be difficult to enforce. But it will be a plus if it helps doctors overcome their reluctance to have these difficult talks. Death is failure in the eyes of some physicians. And some simply don't know how to talk about dying, and fear signaling to the patient that they've given up. Medical schools and residency programs need to do a better job preparing doctors to provide this service.

We should revisit the provision of national health care reform that drew such scorching political fire last year. All it would have done was authorize Medicare to pay doctors to sit down - at a patient's request - once every five years to talk about end-of-life care. To explain the optional approaches to treatment, answer questions and find out what's important to each patient. That's it. No pleading with bureaucrats for treatment. No death panels. It's a conversation doctors and patients need to have.

It's a discussion the public, and our elected officials, need to have. hN