Letters to the Editor

Physicians Should Be Aware of Patient's Disease Progression

TO THE EDITOR: As a family physician turned hospice team physician, I read with interest the article and accompanying patient education handout on the effectiveness of medications for chronic obstructive pulmonary disease (COPD). The Journal of Family Practice also recently published a supplement on the diagnosis and multifaceted management of COPD.1 Family physicians strive to have a whole-patient approach to illness that includes continuity of care across the disease spectrum and addresses quality of life even as death approaches. I was hopeful to see this continuity approach applied here. Unfortunately, I feel both articles stopped short of this goal.

The focus of the article in American Family Physician was to examine the effectiveness of medications in achieving stated goals of treatment: "improve quality of life, exercise tolerance, sleep quality, and survival; and to reduce dyspnea, nocturnal symptoms, exacerbations, use of rescue medications, and hospitalizations." The fact that the article focuses on evaluating treatments to improve survival and quality of life highlights that the disease is progressive and ultimately can result in untimely death.

For this reason, I believe both articles missed an opportunity to remind us that we should be continually reviewing those treatments that hope to extend life and should also remain aware of disease progression and identification of "nodal points" for considering transition to palliative therapies. Recognizing factors that identify when patients may receive limited benefit from therapy and/or have a life expectancy of less than one year will remind us to have meaningful discussions with our patients about goals of care before treatment decisions are demanded urgently in intensive care unit settings.2

The exclusion of this type of information in articles that discuss active treatments, and in patient education handouts, perpetuate situations whereby patients with chronic illness and gradual deterioration are seen by residents and family physicians to be "suddenly dying" only in the penultimate hospitalization despite multiple signs of impending mortality.3 This late recognition of disease progression leads to missed opportunities for closure, symptom control, patient and family support, and the "good death" we all hope for.

MaryBeth Salama, MD

Pittsburgh, PA
E-mail: MaryBeth.Salama@vitas.com

Author disclosure: Nothing to disclose.

REFERENCES

1. Chapman KR, Doherty DE, Martinez FJ, Belfer MH. Multifaceted COPD Management. J Fam Pract. 2007;10(Suppl):S14-S27.

2. Mast KR, Salama M, Silverman GK, Arnold RM. End-of-Life content in treatment guidelines for life-limiting diseases. J Palliat Med. 2004;7(6):754-773.

3. Russ AJ, Kaufman SR. Family perceptions of prognosis, silence, and the "suddenness" of death. Cult Med Psychiatry. 2005;29(1):103-123.

Approaching the Conversation of End-of-Life Treatment Options

TO THE EDITOR: The article on end-of-life care provided a number of useful practice suggestions for communicating effectively and compassionately with patients and their families who are dealing with the difficult issues that accompany terminal illness. The authors appropriately identified the frequently asked question, "Do you want us to do everything that we can to keep you alive (e.g., artificial life support)?", as one which often leads patients and families to conclude that choosing anything other than all available care means not obtaining the best available care. Framing questions in this fashion, without providing appropriate medical context, leaves patients and families at a tremendous disadvantage to discern what alternatives and approaches might be available to them to obtain the most effective end-of-life care.

An alternative approach would be to initiate this type of conversation by posting a positive framework: "In the event you become extremely ill, I would suggest we use treatments that offer a real chance at meaningful recovery, and not embark on treatments that do not offer a real opportunity to provide you a meaningful benefit. Would you like to talk about the types of therapies that might fall into each category?" This approach has been effective in helping patients and their families cope with the difficult situation of terminal illness care in a way that is collaborative and appropriately shares decision-making among patient, family, and physician.

Marvin A. Dewar, MD, JD

Gainesville, FL
E-mail: dewarm@shands.ufl.edu

Author disclosure: Nothing to disclose.

Send letters to Kenny Lin, MD, Assistant Editor, American Family Physician, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

Please include your complete address, e-mail address, telephone number, and fax number. Letters should be fewer than 500 words and limited to six references (including citation of original article) and one table or figure.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.