I began reading August Farewell on the seventh day of that summer month. The date coincides with the beginning of David Hallman’s narrative of his lover’s death two years prior, and memory of their decades-long relationship.
A book by a gay Canadian Christian man might seem remote to a woman like me, who’s married, Jewish and lives in New York City. But Hallman connects, effectively; his story sticks and might influence the near-death arrangements of any person living in our modern world.
Hallman recounts the death of a man, his partner William (Bill) Conklin, who’d lived for years with multiple sclerosis and its debilitating effects. In August, 2009 Conklin learned he had advanced pancreatic cancer. The story works through the author’s 16 daily notes on meetings with doctors, nurses and palliative care specialists, and visits with old friends and family.
The patient chose to die at home and his partner,
See more August Farewell: A Short Tale of a Peaceful Ending of Life
We’re up to point 9 on the list – and nearing the end — on Bending the Cost Curve in Cancer Care from the May 26 NEJM. The suggestion from Drs. Smith and Hillner is that doctors better integrate palliative care into usual oncology care.
The authors start this important section well:
We can reduce patients’ fears of abandonment by means of better-integrated palliative care. This topic is fraught with misunderstanding given the references to “death panels” during the recent debate concerning health care legislation…
Here they’re on target: Some patients think, mistakenly, that inclusion of palliative care in their treatment means their doctors are throwing in the towel. I’ve known some oncologists who think the same, who perceive palliative care as a last resort.
The truth is that palliative care, which aims to relieve symptoms, can be implemented at any point in the treatment of disease.
The authors go
See more Reducing Costs by Better Integration of Palliative Care in Cancer Treatment
We’ve reached the second half of our discussion on Bending the Cost Curve in Cancer Care. The authors of the NEJM paper, Drs. T. Smith and B. Hillner, go on to consider how doctors’ behavior influences costs in Changing Attitudes and Practice. Today’s point on the list: “Oncologists need to recognize that the costs of care are driven by what we do and what we do not do.”
In other words (theirs): “The first step is a frank acknowledgment that changes are needed.” A bit AA-ish, but fair enough -
The authors talk about needed, frank discussions between doctors and patients. They emphasize that oncologists/docs drive up costs and provide poorer care by failing to talk with patients about the possibility of death, end-of-life care, and transitions in the focus of care from curative intent to palliation.
They review published findings on the topic:
In a study at our institution
See more Reducing Cancer Care Costs: Oncologists Need to Get a Grip on Reality, and Talk about Dying
This is the sixth post on Bending the Cost Curve in Cancer Care, based on the 10 suggestions put forth by Drs. Smith and Hillner in the May 26 NEJM. We’re up to number 5 on the list for changing oncologists’ behavior: by limiting further chemotherapy to clinical trial drugs in patients who are not responding to three consecutive regimens.
Giving one drug or combination regimen, and then another, and another, and another, to cancer patients whose tumors resist multiple regimens is more likely to cause harm than good. Oncologists need be realistic with themselves and with their patients, in a kindly way, when treatments fail.
Options to consider, besides chemo, include palliation (which can be started at any time, including before and during chemotherapy), alternative approaches (such as hormonal or immune-based therapy, for some tumors), hospice care and participation in a clinical trial, as the authors suggest,
See more Lowering Cancer Care Costs by Limiting Chemotherapy in Patients Who Aren’t Responding
Recently the NEJM ran a Sounding Board piece on Bending the Cost Curve in Cancer Care. The authors take on this problem:
Annual direct costs for cancer care are projected to rise — from $104 billion in 20061 to over $173 billion in 2020 and beyond.2…Medical oncologists directly or indirectly control or influence the majority of cancer care costs, including the use and choice of drugs, the types of supportive care, the frequency of imaging, and the number and extent of hospitalizations…
The article responds, in part, to Dr. Howard Brody’s 2010 proposal that each medical specialty society find five ways to reduce waste in health care. The authors, from the Divisions of Hematology-Oncology and Palliative Care at Virginia Commonwealth University in Richmond VA, offer two lists:
Suggested Changes in Oncologists’ Behavior (from the paper, verbatim — Table 1):
1. Target surveillance testing or imaging to situations in which a
See more Running 2 Lists That Might Lessen the Costs of Oncology Care
It was sometime in April, 1988. I was putting a line in an old man with end-stage kidney disease, cancer (maybe), heart failure, bacteria in his blood and no consciousness. Prince was on the radio, loud, by his bedside. If you could call it that – the uncomfortable, curtained compartment didn’t seem like a good place for resting.
See more How to Avoid Death in the ICU
Here’s my short list, culled from newsworthy developments that might improve health, reduce costs of care and better patients’ lives between now and 2020, starting this year:
1. “Real” Alternative Medicine. By this I don’t mean infinitely-diluted homeopathic solutions sold in fancy bottles at high prices, but real remedies extracted from nature and sometimes ancient practices.
A good example is curcumin, a curry ingredient from the root of the turmeric plant. We’re just starting to uncover this compound’s anti-cancer effects in humans. Another natural antidote that’s gaining ground is green tea; scientists are sifting through its components to see how it reduces cell growth in some forms of leukemia and other tumors.
2. Chemotherapy Pills. Why get treatment through an intravenous catheter if you can pop some pills instead? To be clear, some of the best and most effective cancer therapies require infusion. And just because a medication can be
See more Looking Ahead: 7 Cancer Topics for the Future