Distributed October 1998
Copyright ©1998 by Joan M. Teno, M.D., and Edward Martin, M.D.
By Joan M. Teno, M.D., and Edward Martin, M.D.
Joan M. Teno, M.D., is an associate professor of community health at Brown University School of Medicine and a staff physician at Hospice Care of Rhode Island. Edward Martin, M.D., is medical director of Hospice Care of Rhode Island and a clinical assistant professor of medicine at the Brown University School of Medicine.
Debate is now the norm in our confrontational culture. However, let us look beyond the polarizing language. A recent study conducted by Brown University faculty found that one in four cancer patients with daily pain in nursing homes did not have any analgesics prescribed - not even aspirin. There is a common ground that all parties can certainly agree upon: improving the quality of care for the vulnerable, terminally ill members of our society. Regardless of the views concerning the morality of physician aid to the dying, we can all agree that now is the time to move from debate to dialogue on how specifically we can provide quality medical care for those in the final years of life.
A critical first step is recognizing that dying is an important phase of life. It is time we all start talking about what we all silently realize, that we are all dying. The National Hospice Photography exhibit opens at the Bell Gallery Oct. 24. This is an important opportunity to begin a dialogue here in Rhode Island on how we care for dying persons and their loved ones. See the exhibit, but don't just take a quick look. Truly linger and see the stories, the humanity of people living well in the shadow of death. A toddler reaching out to touch her smiling grandfather's nose reminds us that there are moments to be cherished at life's end. This is a difficult phase of life; yet many said that it is a meaningful part of life. The dying must not be discarded. They are vital members of our society. The quality of care that we provide for them is a litmus test of the soul of our society.
We call on our state government and others to promote a community dialogue on what is quality care and how we can best monitor it. In the midst of the managed care revolution, examining the quality of care of the dying is important. The dying are the proverbial canaries in the coal mine. Caring for them truly tests whether a health care plan can provide compassionate and coordinated medical care. It is time that we monitor the quality of care for this vulnerable population.
Here are some important questions Rhode Islanders should consider: Do health care providers explain their treatment options to patients in an understandable way? Does the health care plan provide access to the needed subspecialty care? How many people die where they wanted to die? How many die in pain? We simply don't know the answers to these questions but would guess that too many die in pain. It is time that we found out. Knowing the extent of the problem is a vital step in improving medical care.
Is physician aid to the dying immoral? We have chosen not to answer that question. As physicians, we are rarely asked to help our patients die. A more substantial and morally troubling problem is that too many die in pain. This is not because we await some breakthrough in medical research. The major barrier to pain control is the reluctance of physicians to prescribe medications necessary to relieve suffering. Physicians often express concern that they will be unduly scrutinized and punished for prescribing medications in the dosage and manner necessary to relieve the symptoms that dying patients experience. This despite assurances from medical associations and medical boards that this is not the case. No one can predict whether HR 4006 will have the predicted chilling impact on physicians treating pain. Will physicians, for example, fear that there is a DEA agent overlooking every prescription that they write? We don't know, However, now is the time to seek a common ground: to improve the quality of care for the dying patient.######