If spending my days as a hospice and palliative care physician has taught me anything, it’s that cancer is everywhere. Obviously, I deal with cancer patients on a daily basis, but it seems that even in my personal life, few weeks pass without hearing of someone else receiving the diagnosis. Part of it is my age. As I get older, I’m inching into the demographic where the incidence is rising. Also, I become more aware of my own mortality, so I take notice more than I did in my twenties. However, the truth is that the incidence of cancer is increasing. The reasons are multi-factorial and too complex to dissect here.
The other thing I continue to notice is that while modern medicine is pretty good at treating acute illnesses, we stink at prevention. This has led me to dive deeply into disease prevention over the last few years. The point as it relates to cancer is that two thirds of cancer can be prevented with lifestyle modifications (nutrition, exercise, don’t smoke, etc.). It is estimated that one-third of cancer can be prevented with routine exercise alone. The reason is not some nebulous process where exercise magically prevents problems. It is a very complex, but real, set of processes that occur with regular exercise that are being elucidated more and more each year. There are numerous physiologic, neuro-hormonal responses that are beyond the scope of this discussion that help prevent the equally real processes that lead to cancer development. This link is to the National Cancer Institute’s informational page on physical activity and cancer. It’s very basic and I encourage everyone to glance at it and see if you can find the motivation to get moving!
Jason Tibbels, MD
A study released last week in the American Heart Journal confirmed a continued disparity in hospice utilization among whites and nonwhite patients. The study looked at about 220,000 patients with heart failure who died between 2000 and 2008. The study found that nonwhites were 20% less likely to be enrolled in hospice, and when they were, they had higher resource use after enrollment. This is consistent with previous studies that have found the same type of disparities. For example, an ongoing Harvard study found that black people are two to three times more likely to want to be kept alive and die in intensive care. These findings are often attributed to decades of mistrust of the medical community as well as a culture that values life, even in its most debilitated state. These concerns are supported by studies that have found minorities tend to receive lower quality healthcare than whites even when things like insurance status, severity of disease, etc. are all comparable.
Obviously, the reasons behind lower use of hospice among minorities are multifactorial, but the solution remains the same. Lack of information, perceived financial barriers, and access to care all contribute to the issue and can be addressed with education. We must continue to make people more aware of hospice, and quality end-of-life palliative treatments so that everyone can make choices that meet their medical goals. That is not to say that everyone should, or will, choose hospice care, but everyone deserves to have the best information available when these difficult choices arise.
A recent Associated Press article highlights the growing demand for hospice care being lead by the baby boom generation.
“As they brace for the eventual needs of the aging baby boom generation, hospice providers are working to diversify their services and dispel misconceptions about what they do.”
I found this article a pretty interesting discussion of the changing scope of hospice and palliative medicine in our country. The Baby Boomers are coming! My favorite part of the article is where industry leader Dr. Ira Byock talks about this generation having something to say about how they will deal with end-of-life care:
“We often quip that in hospice care these days, we’re doing brink-of-death care rather than end-of-life care,” Byock Said.
When it comes to illness, dying, and death, the American mindset is “I don’t want to think about it.” But Byock hopes baby boomers will “take back” the end of life in the same way they took charge of the beginning by pushing for the natural childbirth movement and efforts to bring fathers into the delivery room.
“It was driven by the boomers as citizens and consumers; it was an advocacy movement. A very similar thing needs to happen now,” he said.
Do you see the glass half empty or half full? I have hated that question from the first time someone asked me this overused, and now trite attempt to somehow evaluate how I see the world. As a kid, my answer was always the same, “It is almost certainly neither as I doubt you took the time to measure it perfectly, but in the event that you did the answer is obvious…it’s both.”
So with that aside, let’s throw out my pragmatic and somewhat cynical approach to the question and look at what it’s trying to ascertain. Are you an optimist or a pessimist? The answer probably depends on the situation, your mood, and myriad other factors, but in general which are you? Why am I asking this? If you’re like me, you need a reason to care. There are plenty of ways to frame this discussion whether it’s psychological, spiritual, or philosophical. Today, I’m simply going to point to a very practical reason to be more optimistic.
Anyone who knows me, or has read some of my articles, knows how strongly I feel about end-of-life planning (advanced directives, living will, etc.). For some reason, our culture seems to avoid these discussions as if ignoring death will somehow help us avoid its inevitability. It seems odd that people who have such a strong legacy of attacking situations head on and bringing issues to light are so passive when it comes to this topic. More irritating is how end-of-life has been politicized and boiled down to emotional catch phrases like “death panels”.
A recent article from the New York Times titled Taking Responsibility for Death does an outstanding job of making many of my points. I strongly urge you to read the entire article, but if you need the snapshot takeaway then read these last two paragraphs and ask yourself if you have taken responsibility for dying on your own terms.
There is a clear contradiction between the value that American society places on personal choice and Americans’ reluctance to make their own decisions, insofar as possible, about the care they will receive as death nears. Obviously, no one likes to think about sickness and death. But the politicization of end-of-life planning and its entwinement with religion-based culture wars provide extra, irrational obstacles to thinking ahead when it matters most.
As someone over 65, I do not consider it my duty to die for the convenience of society. I do consider it my duty, to myself and younger generations, to follow the example my mother set by doing everything in my power to ensure that I will never be the object of medical intervention that cannot restore my life but can only prolong a costly living death.