Feature: MSU Advances End-of-Life Care
MSU is pioneering “palliative care” programs designed to help patients better endure their “end of life” stage.
Richard Johnson, a 44-year-old, married businessman with two children who had never experienced a serious illness, suddenly found himself overwhelmed with decisions to make after being diagnosed with colon cancer last winter. Not sure where to turn, Johnson accepted his doctor's advice without question, undergoing surgery and beginning chemotherapy within a week of his diagnosis. Despite these aggressive medical efforts, however, Johnson's cancer spread and his condition worsened. By the end of spring, his prognosis was grim: The cancer was incurable and death, probably by Thanksgiving, inevitable.
Despondent and in shock, Johnson fell into a severe depression, aggravated by his increasing loss of control of his bodily functions and severe pain. Johnson's physician, though greatly saddened by his patient's condition, could offer little more for him than comforting words and advice to 'get his affairs in order.' Always honest with his patients, he explained to Johnson that terminal cancer ended in a painful death and little could be done about that, although he did prescribe low doses of narcotics to Johnson for his 'agonizing pain.'
By summer's end, Johnson was desperate. He had accepted his inevitable death but wanted to end his days better than he was; his physical misery, however, was not allowing him to do anything. He couldn't move without pain, and conversation, his last pleasure in life, was impossible through the wall of suffering he had come to accept. He couldn't even think for long periods of time due to his suffering. His greatest regret was that his desire to come to terms with his death and help his family face it was proving futile. A phone call from a sympathetic old friend, Walter Harris, proved to be the turning point.
Harris had had cancer two years earlier and, although his wasn't fatal, he indicated that he had been helped through a very painful, debilitating six months with medical interventions that he had learned about through an educational CD, Easing Cancer Pain. He hand-delivered a copy to Johnson that day, and together they reviewed it. Although Johnson realized he couldn't be cured, the CD offered him great hope for his last months of life.
Armed with the latest information on pain relief and end-of-life care, Johnson realized that his suffering wasn't necessary, despite his terminal diagnosis. He contacted the resources he found listed on Easing Cancer Pain, including the American Cancer Society and the Cancer Pain Initiative. These organizations then linked him to health providers in his area who, although aware of the terminal outcome of his illness, focused on treating the symptoms that were making his last months of life intolerable.
Within a week, Johnson, though still deteriorating, felt better. He could carry on a conversation, feed himself, and move without agony. Freed from the paralyzing agony that had defined his life, Johnson began the life closure he wanted—time to resolve issues from his past and time to say good-bye to family and friends. He died a week before Thanksgiving, sorry to leave this world but thankful that his final weeks were lived more fully than he had thought possible just two months earlier.
Although Johnson is a fictitious name, countless patients have heard from their physicians, 'There's nothing more we can do.' But in fact, as the Johnson case illustrates, they are untrue, both from the viewpoint of good medical practice and as a matter of human compassion. Doctors can do a great deal more for patients suffering from a terminal illness, and faculty at MSU’s College of Human Medicine (MSU-CHM) are leading the way in getting that message out. They are addressing situations where cure is no longer possible with an approach to treatment known as palliative care.
Focusing on comfort and quality of life, palliative care allows patients to make the transition from life to death in a dignified and pain-free manner, with all the support that medical science can provide. In keeping with MSU's land-grant philosophy, CHM faculty are meeting this goal on two fronts—first, in the classroom, where medical students are learning that their role as physicians does not end with a terminal diagnosis, and second, in the community, where faculty are active in outreach programs aimed at helping Michiganians find out about palliative care options and empowering them to get the help they may need.
THE CHM CURRICULUM
So much of medical education revolves around saving lives that the treatment of people whose lives cannot be saved can easily be ignored. But medical advances also mean that people live longer with chronic and even terminal illnesses, and so the challenge of offering good and continuous care to those who can’t be cured grows ever greater. At MSU, students are learning that treatment continues well beyond the terminal diagnosis; only the goals of treatment change. At the CHM, learning how to provide appropriate medical care for dying patients is a vital component of medical education that has been integrated throughout the curriculum.
The core components of the palliative care curriculum include symptom management for patients with terminal illnesses, especially regarding pain relief; the emotional and spiritual dimensions of the end of life; and coordinating care with other health professionals. Beginning with their first-year courses, medical students learn about aging, death and dying as matters of human development, and grief and loss in childhood and the special needs of dying children. Students are introduced to the MSU-created CD-ROM program Easing Cancer Pain, which contains audiovisual clips of patients facing terminal illness. Other courses include interviewing patients and dealing with patients experiencing chronic and acute pain. Second-year students learn more about treating pain.
Pain is one of the most poorly assessed and treated symptoms of terminal illness, and fear of pain is often a much larger concern for patients than fear of death. CHM students learn how to evaluate the subjective experiences of pain and how to relieve it effectively, particularly with the appropriate use of opioids. Independent learning on these subjects is encouraged through the use of several web-based programs designed by the CHM, including one devoted to pain evaluation and management.
In their third year of training, when medical students are assigned to one of six communities throughout Michigan, pain and symptom management, palliative care, and clinical work with grief are part of the 'Core Competency' series of seminars that form the foundation of their clinical medical education. Additionally, students are assigned self-paced and self-instructional course work through the Internet to complement their community-based clinical learning in these areas. Clinical training also includes working with hospices in the community.
COMMUNITY SERVICE
Karen Ogle, M.D., director of the Palliative Care Education & Research Program at the Cancer Center at Michigan State University (www.palliativecare.msu.edu) and professor in the Dept. of Family Practice in the College of Human Medicine, has devoted much of her professional life to improving care for the terminally ill—educating medical students and physicians as well as the public on issues of care for the dying. Dr. Ogle's efforts in this arena were recently recognized by Gov. John Engler, who named her chair of the newly-formed Commission on End-of-Life Care (www.endoflifecare.msu.edu). 'Improving humane and dignified treatment during life and at the end of life has long been a priority of mine,” the Governor says. “The Commission on End-of-life Care . . . will build on our efforts to provide quality care for the sick and dying."