Palliative Care Is Like Memory Foam

Yesterday, a patient told me that “nothing was being done” to treat the cancer that had been diagnosed four months ago. I pulled up the most recent oncology note in the computer and read the details to him. Of course the oncologist had told him everything I was telling him. Why did the patient not know that he had a follow-up appointment scheduled? The clue was at the end of the note. “Patient is requesting Valium. Will defer to his primary care provider.” A complicated diagnosis and treatment plan was carefully laid out to a patient who was too anxious to hear any of it.

This was the first time I met this patient in Palliative Care clinic, and the most obvious thing about him, the point that dominated the resident’s presentation, was the patient’s anxiety. Apparently the resident was so impressed by the anxiety, that he neglected to tell me some pertinent medical history before I entered the room. Thinking back on it, I wonder whether the resident had the misguided notion that Palliative Care is only about psychosocial issues, not about practicing good clinical medicine. I hope he learned from my example as I looked up the summary of the hospitalization from last August and all of the oncology notes.

When residents come to Palliative Care clinic for the first time, I tell them it’s no different from practicing Internal Medicine, but with a slightly different focus. I use the acronym GAPS to help them remember what to focus on in addition to the standard medical assessment.

• G is for goals of care. We try to make sure patients fully understand their diagnosis and prognosis before we move on to help with decision-making about which treatments to pursue or forego.
• A is for advanced directive. Most patients who come to Palliative Care clinic with an advanced chronic illness or terminal disease are appropriate to have a POLST* form filled out.
• P is for psychosocial. The patient’s mood and family supports are carefully assessed.
• S is for symptom management. Symptoms include nausea, lack of appetite, pain, constipation, fatigue, or restlessness.

*For those not familiar with the POLST form (Practitioner Orders for Life-Sustaining Treatment), much helpful information is available here.

I bristle when Palliative Care is confused with Pain Management, as if that’s all we do. Both Palliative Care and Pain Management are noble specialties, but there are distinct differences in the patients referred to each one.

Even the patients are confused about what Palliative Care is. I ask patients if they know why they’ve been referred to see me. Most have no clue. I explain to them that I’m there to give them an extra layer of support that their primary care and specialist physicians may not be able to provide. That extra layer varies from patient to patient, but, in this man’s case, it turned out to be a listening ear, a confirmation of a follow-up oncology appointment, and a prescription for Valium. It’s all part of being the memory foam of medicine.

There are false perceptions about many professions. Which misconceptions of your job bother you the most?