In a Baltimore neighborhood of simple brick houses, where geraniums edge the lawns in cheery bursts of pink and red, an old woman is dying. On a sweltering summer afternoon, she is in bed, frail and frightened, waiting for her doctor to arrive.
A white Mazda pulls up, and the doctor, Timothy Keay, emerges carrying a blue nylon satchel, the modern equivalent of the black bag. Keay, an associate professor of family medicine at the University of Maryland, is a rarity in this impersonal, technological era: a doctor who makes house calls.
In the house, the air is still. Keay walks upstairs to see his 84-year-old patient. Beneath her thin cotton nightgown, a cancerous tumor the size of a cantaloupe is growing on her left breast. She has refused treatment, save for the clear plastic tubes that pump 2 liters of humidified oxygen into her nostrils each minute.
"Some doctors would say to her, 'Look, either get this operated on or I can't help you,' " said Keay, an expert in the emerging field of palliative care. "That is a stark choice. I say to her: 'It's your life. How can I be of assistance to you?' "
Instead of seeking to cure a patient, palliative care addresses a range of problems, from intense pain to depression, that dying people and their loved ones suffer.
The Supreme Court recently settled one of the most contentious ethical, moral and legal questions of recent decades, deciding that states may ban doctor-assisted suicide. But the ruling does not settle one of the most pressing crises in modern medicine: inadequate care for patients at the end of life.
That is a problem for the health-care profession to solve, and while ethicists and lawyers have been debating the right to die, ++ doctors have been busy examining their practices and their souls. The universal response, from both advocates and opponents of assisted suicide, has amounted to nothing short of a rallying cry for better treatment for the dying - in particular, the brand of medicine that Keay practices, palliative care.
"The assisted-suicide debate has called the question on the health-care profession," said Dr. Steven Miles of the University of Minnesota, an expert in end-of-life care. "The public is demanding assisted suicide, in part because they are justifiably afraid of the quality of end-of-life care. There is a demand for a new paradigm, and the paradigm is palliative care."
Just how palliative medicine will be incorporated into American health care, however, remains a huge question. It is as much a philosophy as a discipline, blending the hard-and-fast science of pain management with a focus on emotional and even spiritual matters, like the nature of suffering, that reach far beyond the traditional realm of medicine.
Return to art of dying
In a sense, palliative care signals a return to the past, to the centuries-old notion of ars moriendi, the art of dying. With roots in the hospice movement, palliative medicine has long been ignored by most American doctors. It is not taught in medical school and is not a recognized specialty in the United States, although it is a specialty in Britain and Australia. Suddenly, however, palliative medicine is in vogue. Palliative-care teams are springing up at some of the most sophisticated medical centers. In New York, the United Hospital Fund is financing a $1.1 million effort to install palliative care in five city hospitals.
Medical schools are taking the first tender steps toward incorporating the palliative-care philosophy into their curriculums. Doctors like Timothy Keay are busy teaching their techniques to colleagues and medical residents.
"We call it the silver lining," said Dr. Susan Tolle, director of the Center for Ethics in Health Care at Oregon Health Sciences University. In 1994, several days after Oregon voters had approved a measure to legalize assisted suicide, Dr. Tolle's university stitched together a "comfort care team," a doctor, a nurse, a pharmacist, a social worker and a chaplain who act as a consulting service to those who care for dying patients.
Though the measure never took effect and Oregon voters will go to the polls on the issue again in October, Dr. Tolle senses a change in her colleagues' attitude. "You can feel doctors trying harder," she said.
Indeed, so much attention is being paid to palliative care that longtime advocates are stunned. Dr. Ira Byock, president of the American Academy of Hospice and Palliative Medicine, was recently the keynote speaker at a conference on palliative care in New York City. Surveying the standing-room-only crowd in a ballroom at the Marriott Marquis Hotel on Times Square, he said, "Two years ago, I couldn't get in to see some of the people who now hug me."
One of the first principles of palliative medicine is that patients should not die in pain, and that is an area in which research shows that mainstream medicine is failing miserably. A widely publicized study published in 1995 by the Journal of the American Medical Association found that among 9,000 acutely ill patients in teaching hospitals, half had spent their dying days in moderate or severe pain. Experts say that is because many doctors simply do not know how to prescribe properly the extraordinarily high doses of narcotics that some dying people need.
Pub Date: 7/20/97