While I intellectually understand the need for palliative medicine providers and am encouraged by the growth of the specialty, I’m conflicted.  In my heart, I feel that the rise of palliative medicine as a specialty represents an indictment of medicine as it is practiced in the United States today and that instead of making a new specialty, the practice of medicine needs to change.   Where are the kindly general practitioners popularized in the 1970’s TV show Marcus Welby, M.D., who knows their patients intimately and steers them to the proper medical treatments.  Maybe this type of practitioner never existed, and likely that model is too paternalistic in any case.  But I think the sometimes gruff, but always caring and compassionate fictional Dr. Welby who knows his/her patients intimately is what we aspire to be.

Certainly, medicine was a lot simpler in the 1970s, and so the practice of medicine was very different. In those years, for example, there were few choices for medication management of hypertension or congestive heart failure (CHF), so if patients had side effects from the medications there were few alternatives. And premature death from these diseases was common.

Operations such as coronary artery bypass grafting (CABG) were a major deal and families worried that their loved ones might not make it through the operation, let alone lead a normal life again. Back then, post-CABG, patients routinely remained intubated for days and hospitalized for weeks. Now, many patients are helped by stent placement alone, and when CABG is necessary, most patients are extubated soon after the operation is completed and are home within days. The majority of patients have excellent outcomes and go on to lead full lives.

It’s inarguable that medicine has changed dramatically over the past few decades. But while medical treatment options have become ever more complex, providers have less time to spend helping patients make treatment decisions (that these time constraints are predominantly due to our dysfunctional health-care payment system is a diatribe all its own).

For example, intravenous (IV) inotropes and left ventricular assist devices as destination therapy have dramatically changed the treatment for patients in the end stages of congestive heart failure. Yet these advanced therapies bring with them another set of challenges. They may keep the patient alive, but at what burden to the patient?

Often, palliative medicine providers are called in after advanced therapies (for example, IV inotropes or high-flow nasal cannula oxygen) are started because the patients are found to be permanently dependent on the therapy, and going home or even to a skilled nursing facility may not be possible due to logistic or insurance constraints. The patient is essentially “stuck” in the hospital, and then palliative medicine specialists are consulted “to discuss treatment goals.”  But, it’s kind of late to be talking about goals at this point, isn’t it?

Mr JT, a 73 yr old male, has systolic heart failure with an ejection fraction of 25%.   Despite this, he remains active and independent.  He is referred for AICD placement (automatic implantable cardioverter-defibrillator) as a means for primary prevention of sudden death due to arrthymia. Typically, the consent process includes a discussion of the indication for the AICD—“prevent sudden death”—and the risks and benefits inherent to the procedure.   After all, everyone wants to avoid death, right?

But what if, for JT, a fate worse than death would be a life of increasing dependence and repeated hospitalizations.   He had watched his father die a long, slow death from COPD, and he had vowed to himself to never burden his family in that way.   Does he know that the disease trajectory for patients with CHF is similar to that for COPD?  Perhaps a sudden/precipitous death might be preferable to a long decline.   So, for Mr JT, would he truly be helped by the placement of an AICD?

In theory, during the old Marcus Welby MD days- JT’s family physician likely would have known his wishes, because they had a long history together.  But now, providers don’t have these types of relationships- which is sad for provider and patient alike.  So today, more than ever, good communication skills are critical, for providers to really help patients think about their overall treatment goals when deciding on a course of treatment.  This is how providers avoid becoming ‘ordering technicians’ and work with their patients in partnership.  And it’s why, homing one’s basic communication skills is just as important as keeping up to date with the newest treatment options.  Because this is the type of discussion that needs to happen before the AICD is placed.