The Importance of Communication
Good communication is a key part of providing comfort care. As patients near the end of their lives, it’s important for them to talk about their goals and wishes with the medical team. Do they want their lives prolonged as much as possible? Or would they prefer comfort care? The problem, says Dr. V.J. Periyakoil, director of palliative care, education, and training at Stanford University’s School of Medicine, is that doctors often don’t communicate effectively with their patients. “And so what happens is the default takes over,” said Periykoil, “When patients get sick, they call 911, they end up in the emergency room. If they’re seen as pretty sick, they then get escalated to the Intensive Care Unit. And then all sorts of procedures and treatments are given. Because all this happens in a very short and very intense time, there is not time to press pause and say ‘What matters to you? What do you want?’ ”
Modern Medicine’s Focus on Curing Disease and Prolonging Life
End-of-life care received very little attention, when advances in medicine took off in the 50’s and 60’s. Curing illness and disease became the focus of modern medicine and as a result, people lived longer and better than at any time in history.2 In 1995, a ground-breaking study3 funded by the Robert Wood Johnson Foundation surveyed ten thousand terminally ill patients and found that at least half of them experienced unwanted pain and suffering after weeks of expensive, ineffective treatments.4 The study’s results were a wake-up call for the medical system, but the response was slow. Most physicians and nurses currently in practice have little or no formal training in basic end-of-life care.5 As recently as twenty years ago, most medical schools still did not offer courses in end-of-life care.
But times are changing. Today, palliative care is part of courses offered by almost all medical schools.6 California has made significant progress in supporting and expanding palliative services in medical schools, hospitals, and hospices.7 “We are definitely better than we were twenty years ago,” said Periyakoil. But despite the progress, Periyakoil argues there’s still a long way to go. She said, “Recently, the Institute of Medicine did a twenty-year follow up on looking at the state of end-of-life care in the U.S. and found that some major gaps that need to be addressed before we can actually claim that we are very good at providing care for patients at the end of life.”
There’s a serious shortage of palliative care specialists. For every 1200 terminally ill patients, there’s only one specialist available on average.8 Not too many physicians choose to specialize in fields like palliative care and gerontology—the pay is too low compared to other specialties like cardiology or plastic surgery.