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Perspective
Becoming a Physician: Freedom from the Tyranny of Choice — Teaching the End-of-Life Conversation
Thirty years ago, an intern had a conversation with a patient that he regrets to this day. The patient, a young man with widely metastatic lymphoma, unresponsive to chemotherapy, now had progressive dyspnea. The intern knew that even with intubation, his patient would soon die. Although the norm at…
Images in Clinical Medicine
Hypertrophic Pulmonary Osteoarthropathy and Tripe Palms
Figure 1.
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Perspective
Painful Inequities — Palliative Care in Developing Countries
When Artur, a former KGB agent in Ukraine, developed prostate cancer that metastasized to his bones, his pain grew so intense that he moved hours away from his family so they would not witness his suffering. "I don't want them to see me cry," he said. Lacking access to the opioid regimens that we…
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Sounding Board
Bending the Cost Curve in Cancer Care
Annual direct costs for cancer care are projected to rise — from $104 billion in 2006 to over $173 billion in 2020 and beyond. This increase has been driven by a dramatic rise in both the cost of therapy and the extent of care. In the United States, the sales of anticancer drugs are now second…
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Perspective
The Palliative Care Information Act in Real Life
New York's Palliative Care Information Act took effect on February 9, 2011. Sponsored by the advocacy group Compassion and Choices New York, the law on its face simply mandates that physicians practice good medicine in caring for patients with a poor prognosis: "If a patient is diagnosed with a…
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Perspective
The Power Proxy
The patient looks better than I expected. Investigations for a septic episode revealed a liver replaced by tumor, the primary obscure. He cuts a handsome figure at 70. His handshake is brisk, his expression open and warm. "Hello," I greet him. "I'm the oncologist." "I know all about you, doc!"…
Original Article
Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer
The quality of care and the use of medical services for seriously ill patients are key elements in the ongoing debate over reform of the U.S. health care system. Oncologic care is central to this debate, largely because anticancer treatments are often intensive and costly. Comprehensive oncologic…
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The authors randomly assigned patients with metastatic lung cancer to receive either standard oncologic care or early palliative care, focused on symptom control and psychosocial support for patients and families, together with standard oncologic care. Patients receiving early palliative care had lower rates of depression, a better quality of life, and better mood scores. They also received less aggressive care at the end of life, but surprisingly, had significantly longer survival than did patients receiving standard care alone.
Editorial
Palliative Care — A Shifting Paradigm
Palliative care focuses on relieving suffering and achieving the best possible quality of life for patients and their family caregivers. It involves the assessment and treatment of symptoms; support for decision making and assistance in matching treatments to informed patient and family goals;…
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Perspective
Medical Marijuana and the Law
The U.S. legal landscape surrounding "medical marijuana" is complex and rapidly changing. Fourteen states — California, Alaska, Oregon, Washington, Maine, Hawaii, Colorado, Nevada, Vermont, Montana, Rhode Island, New Mexico, Michigan, and most recently, New Jersey — have passed laws eliminating…
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Editorial
Reversing the Code Status of Advance Directives?
Twenty years ago, Congress passed the Patient Self-Determination Act, hoping to improve end-of-life care through the use of advance directives. The statute stimulated the development of a cornucopia of planning documents. Patients can sign a living will that states that they do not want their lives…
Special Article
Advance Directives and Outcomes of Surrogate Decision Making before Death
Advance directives document patients' wishes with respect to life-sustaining treatment (in a living will), their choice of a surrogate decision maker (in a durable power of attorney for health care), or both. First sanctioned in 1976, advance directives were designed to protect patient autonomy…
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Data from a national study showed that more than one quarter of older adults who died between 2000 and 2006 required decision making at the end of life but lacked decision-making capacity. Most of these subjects had advance directives (living wills, health care proxies, or both) and received care consistent with their preferences. These findings suggest that advance directives are valuable.
Original Article
K-ras Mutations and Benefit from Cetuximab in Advanced Colorectal Cancer
A randomized trial (CO.17) conducted by the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) in collaboration with the Australasian Gastro-Intestinal Trials Group (AGITG) showed that among patients with colorectal cancer that had not responded to advanced chemotherapy,…
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This study examined the mutation status of the K-ras gene in colorectal tumors from patients who were enrolled in a trial of cetuximab, a monoclonal antibody against the epidermal growth factor receptor (EGFR). A survival benefit was found among patients with tumors bearing wild-type K-ras but not among patients with tumors bearing mutated K-ras. Wild-type K-ras is essential in transmitting signals initiated by EGFR.
Perspective
Letting Go of the Rope — Aggressive Treatment, Hospice Care, and Open Access
More Americans are choosing hospice for end-of-life care, but ironically, hospice patients increasingly are forced to give up effective palliative treatments along with aggressive medical intervention. For Joanne Doolin, a 64-year-old mother of three who spent her last 2 years of life fighting…
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Perspective
Legal Regulation of Physician-Assisted Death — The Latest Report Cards
In 2002, the government of the Netherlands explicitly legalized euthanasia and physician-assisted suicide. These controversial end-of-life practices had been openly tolerated and studied for many years before legalization, and Dutch physicians were expected to voluntarily report their participation…
Perspective
The Big Chill — Inserting the DEA into End-of-Life Care
On October 5, 2005, the U.S. Supreme Court heard oral arguments in Gonzales v. Oregon. On the surface, this case is about the legitimacy of physicians' prescribing of medications under Oregon's Death with Dignity Act and whether the federal government can overrule the states in defining "legitimate…
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Sounding Board
Appropriate Use of Artificial Nutrition and Hydration — Fundamental Principles and Recommendations
For two decades, clinicians have been guided by an agreement about the appropriate use of artificial nutrition and hydration (ANH). In general, ANH has been seen as a medical treatment that patients or their surrogates may accept or refuse on the basis of the same considerations that guide all…
Recent events — including the Terri Schiavo case —have involved public questioning of the commonly held belief that decisions about artificial nutrition and hydration should be made in the same way in which decisions about other treatments are made. This article reviews the principles that have guided decisions about the use of artificial nutrition and hydration over the past 20 years. The authors outline their own recommendations for improving decision making about artificial nutrition and hydration.
Review Article
Medical Progress: Advances in Malignant Mesothelioma
Malignant mesothelioma is an aggressive tumor of serosal surfaces, such as the pleura and the peritoneum. This tumor was once rare, but its incidence is increasing worldwide, probably as a result of widespread exposure to asbestos, a factor with which it is associated (Table 1). There is…
Malignant mesothelioma is an aggressive tumor of serosal surfaces, such as the pleura and the peritoneum. This tumor was once rare, but its incidence is increasing worldwide, probably as a result of widespread exposure to asbestos, a factor with which it is associated. The authors review advances made in the past 5 to 10 years in the understanding, diagnosis, and management of mesothelioma.
Perspective
Becoming a Physician: Learning from the Dying
"I thought I would find out what death actually is. I thought I would learn the proper words to speak. . . . I thought I would leave with answers to my questions about the end of life and how people cope with dying. . . . I hoped there would be a protocol to follow when a patient dies that would…
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Case Records of the Massachusetts General Hospital
Case 6-2005 — A 58-Year-Old Man with Esophageal Cancer and Nausea, Vomiting, and Intractable Hiccups
Presentation of Case. Dr. Kevin R. McDonald: A 58-year-old man was transferred to this hospital for management of newly diagnosed adenocarcinoma of the esophagus. Several months before admission, the patient initially had episodes of early satiety and then began to vomit all solid food. He lost 14…
A 58-year-old man with esophageal cancer had nausea, spontaneous vomiting, and intractable hiccups. The discussants review the role of palliative care in the management of distressing symptoms in patients with cancer, emphasizing the importance of the differential diagnosis in identifying the cause and selecting appropriate treatment for each symptom.
