Palliative care: Mainstream model

Efforts to change the culture of dying in acute care settings are no longer on the fringes of medicine. Some physicians have proven that hospice-like care can coexist -- and even cohabit -- with hospitals.

By Vida Foubister, AMNews staff. Feb. 26, 2001.

New York -- The "aha event" that led Diane E. Meier, MD, to start a hospital-based palliative care program grew out of the death of a 73-year-old Latino man.

It had little to do, however, with the admittedly horrible way he spent the last 29 days of life -- his feet and hands tied to the bed in four-point restraints to keep him from pulling out a nasogastric tube. Such a death in an acute care setting, where the tendency is to err on the side of life, is far from exceptional, she explained.

Instead, Dr. Meier, now director of the Lilian and Benjamin Hertzberg Palliative Care Institute at Mount Sinai Hospital in New York City, said she was at first infuriated and then enlightened by the resident on duty and his treatment of this dying man.

"I asked, 'What's going on here? This man is dying. Why is he tied to the bed?' The resident looked at me with tremendous distress in his eyes and said, 'He'll die if I take out the NG tube.' This lightbulb went off over my head: This is not a bad doctor or an evil doctor or even a stupid doctor. He just does not know what to do. He doesn't even know how to think about it."

Dr. Meier and two of her colleagues shared what they had learned from this man's experience in a 1996 New England Journal of Medicine article, "When Too Much Is Too Little." Then they began to look for ways that they could change the culture of dying within their institution.

"Modern medicine was so brilliant at saving lives that we kind of forgot our traditional role of providing comfort at the end of life," said Christine K. Cassel, MD, chair of the Henry L. Schwartz Dept. of Geriatrics at Mount Sinai School of Medicine. "Now we need to take the advances in modern medicine and apply them to relieving suffering." [...]