This is an absolute travesty. Can’t tell you how many times I have had goals of care conversations with my critically ill patients’ families when they come to the ICU. This needs to change. This has inspired a future podcast episode to further raise awareness and advocate. Thank you!
Great! Thanks again. This one would be curious to know if seen in other countries.
Recently had a 92yo stage iv duodenal cancer - more liver mets than actual Mets players - who had a nice 4d icu stay for sbo and aspiration pneumonia - the private oncology practice (run by private equity who have billboards and private transport vehicles for their monopolistic supply chain) told him - you have 3-6months no chemo 1yr chemo. Well the pt’s a living - +amio for his afib worsening, +ngt for 4d as exasperated surgeons really didn’t want to operate, and plus some good ol abx for that aspiration pneumonia. To be fair he seemed like a mentally strong 92 but still - no statistics allow such a statement to be offered precisely and you need to be clearer about side effects.
Would like that decision to occur independent of the numerous downstream financial incentives such a practice has.
No palliative care trigger.
Like you are giving “palliative” chemo but not requesting actual palliative care?!
*who knows how intensivists will be if/once we or ones close to us get there? In my small n of docs who go through similar - (again selecting for ones seen in the icu) it’s not a minor amount that will defer futile care and opt for onc aggressiveness.
It’s natural that people who are desperate to survive would “agree” to more chemotherapy at the end of life — even if the chance of harms exceeding benefits is high. I might do this myself—I don’t trust “this me” to know what I would choose.
I think the idea here is that by referring earlier to PC, peoples freedom of choice is actually increased, because with the additional support along the journey, they have greater resources available when they reach that final desperate place.
Mentioned the private equity because -- yes, we "know" the right thing is to carefully explain risks/benefits, manage palliation, and prepare our patients for the inevitable (whenever it might occur). But, in private equity, profit is the only metric that matters and (like has been said) when the "metric" is the goal the only thing that wins is the metric -- not appropriate patient care. Like in that patient, we've gotten so great at the cardiac (someone needs to do a cost analysis on how much TAVR is actually costing the government through longer social security (when enacted living well into your 90s was not a real concern) payments) or infectious or orthopedic decline things which could have killed him before 92 -- but you can't really screen for duodenal cancer (yet) and so here we go. The guideline is useful and really hoping it can influence care. It's a modest, small and useful thing to do.
This article hits close to home. I had this situation 4 times in the past week- 2 end of life in the icu and 2 on the floor that could at least speak for themselves and hear a balanced perspective.
2 of these patients’ oncologists had NOT mentioned their already stage IV malignancy had progressed *while on platinum*
I find the drive for rvu-per-infusion to be morally repugnant
That alone would make it a tough week. I used to be incredulous when this would happen — like, surely they had these discussions but they’re just blocking it out psychologically. But, nope.
This is an absolute travesty. Can’t tell you how many times I have had goals of care conversations with my critically ill patients’ families when they come to the ICU. This needs to change. This has inspired a future podcast episode to further raise awareness and advocate. Thank you!
I have gotten more used to (?) having to be the one to start these talks in the ICU… but they haven’t gotten any easier.
I think we need Palliative Care credentials as Intensivists. We do it all the time. That will also be in my podcast.
We used to be able to sit for the boards if you did the fellowship right? We do enough of such.
Totally agree
Great! Thanks again. This one would be curious to know if seen in other countries.
Recently had a 92yo stage iv duodenal cancer - more liver mets than actual Mets players - who had a nice 4d icu stay for sbo and aspiration pneumonia - the private oncology practice (run by private equity who have billboards and private transport vehicles for their monopolistic supply chain) told him - you have 3-6months no chemo 1yr chemo. Well the pt’s a living - +amio for his afib worsening, +ngt for 4d as exasperated surgeons really didn’t want to operate, and plus some good ol abx for that aspiration pneumonia. To be fair he seemed like a mentally strong 92 but still - no statistics allow such a statement to be offered precisely and you need to be clearer about side effects.
Would like that decision to occur independent of the numerous downstream financial incentives such a practice has.
No palliative care trigger.
Like you are giving “palliative” chemo but not requesting actual palliative care?!
*who knows how intensivists will be if/once we or ones close to us get there? In my small n of docs who go through similar - (again selecting for ones seen in the icu) it’s not a minor amount that will defer futile care and opt for onc aggressiveness.
Every patient and situation is unique and no guideline should be blindly applied to everyone.
The idea of private equity owning oncology practices is terrifying. But apparently it’s a large trend right now:
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2804123
It’s natural that people who are desperate to survive would “agree” to more chemotherapy at the end of life — even if the chance of harms exceeding benefits is high. I might do this myself—I don’t trust “this me” to know what I would choose.
I think the idea here is that by referring earlier to PC, peoples freedom of choice is actually increased, because with the additional support along the journey, they have greater resources available when they reach that final desperate place.
Mentioned the private equity because -- yes, we "know" the right thing is to carefully explain risks/benefits, manage palliation, and prepare our patients for the inevitable (whenever it might occur). But, in private equity, profit is the only metric that matters and (like has been said) when the "metric" is the goal the only thing that wins is the metric -- not appropriate patient care. Like in that patient, we've gotten so great at the cardiac (someone needs to do a cost analysis on how much TAVR is actually costing the government through longer social security (when enacted living well into your 90s was not a real concern) payments) or infectious or orthopedic decline things which could have killed him before 92 -- but you can't really screen for duodenal cancer (yet) and so here we go. The guideline is useful and really hoping it can influence care. It's a modest, small and useful thing to do.
This article hits close to home. I had this situation 4 times in the past week- 2 end of life in the icu and 2 on the floor that could at least speak for themselves and hear a balanced perspective.
2 of these patients’ oncologists had NOT mentioned their already stage IV malignancy had progressed *while on platinum*
I find the drive for rvu-per-infusion to be morally repugnant
That alone would make it a tough week. I used to be incredulous when this would happen — like, surely they had these discussions but they’re just blocking it out psychologically. But, nope.
This post inspired my latest podcast episode: https://www.healthcaremusings.com/most-oncologists-do-not-refer-to-palliative-care-what/
And…I did the episode in my PulmCCM T-shirt!!!