End-of-Life Choice, Palliative Care and Counseling

The Hospice Optionby Sonja


By Susan Canfora
The Daily Times
September 15, 2012

Talking about death is difficult.

Even for an oncologist, telling a patient treatment isn’t working, they most likely aren’t going to be cured and it’s time to think about a different kind of care is grueling.

“It’s a very hard conversation to have,” said Dr. David Cowall, medical director of Coastal Hospice in Salisbury, shaking his head and recalling spending a minute alone in his office to gather his thoughts before having that talk with patients.

“If we’re not going to cure them, there comes a time to stop treatments and look at comfort and care. Some patients bite your head off when you tell them that. Some tell you off and some go somewhere else,” Cowall said.

Interested in determining if patients are better off continuing traditional medical care or going into hospice, where symptoms are managed, Cowall co-authored the paper “End-of-Life Care at a Community Cancer Center.” It was published in the June 2012 issue of the Journal of Oncology Practice.

Studied were medical records of 400 patients, all who had died and were Wicomico County residents.

About 200 had remained under doctors’ care in their last days and about 200 chose hospice. Both groups had a prognosis of six months or less to live. Five years of cancer deaths were examined.

The mean age at death was 70. Fifty-two percent were male and 48 percent female.

The median length of survival for those in hospice was 8.4 months after diagnosis. By comparison, the median length of survival for those who continued medical care was 5.8 months.

Waiting too long

Cowall said too many patients were referred to hospice within three days of death. Some remained on ventilators, had dialysis or were in hospital intensive care units until death. Such treatment prolongs the dying process “at great expense and great suffering to the patient,” he said.

Cowall wrote the paper in conjunction with Joan Daugherty of Peninsula Regional Medical Center, who called end-of-life care “ important to provide to our community.”

“That’s why we are glad to partner with Coastal Hospice. We are continually looking for ways to improve patient care. People spend a lot of time thinking about these often-difficult decisions, and we are dedicated to helping our patients as much as possible,” said Daugherty, executive director of the Richard A. Henson Cancer Institute at PRMC.

Also authoring the paper were Bennett W. Yu, Sandra L. Heineken, Elizabeth N. Lewis and Vishal Chaudhry.

Side effects of medical treatment cause additional suffering in terminal patients.

“We need to look at people we can’t cure. Aggressive care does not translate to longer life. We want the care of those patients who will die to be dignified and comfortable. If the risks outweigh the benefits, we shouldn’t be doing it,” Cowall said.

If there is a 20 percent or less chance conventional methods such as chemotherapy will save a life, he recommends hospice.

“I wrote the paper because I was seeking the truth. I didn’t know what we were going to find, but I wanted what is best for the community,” he said.

“We want to make the medical community aware of this data and cancer doctors,” said Cowall, who presented his findings at a cancer conference at Peninsula Regional Medical Center.

“A lot of doctors don’t present information about hospice. The doctors’ concept is to provide care,” Cowall said.

Hospice care concentrates on making the patient comfortable, usually at home, unless pain can’t be managed there.

If that happens, the patient can be admitted to Coastal Hospice on the Lake, at Deers Head in Salisbury, where there are 14 beds.

Generally, about 10 of the beds are full. In the counties Coastal Hospice serves — Wicomico, Worcester, Somerset and Dorchester — there are about 160 patients in a typical day.

Coastal Hospice, a nonprofit organization, has been on the Shore since 1980.

Nurses visit patients at home during what is usually the last six months or less of life and medication is administered to keep patients comfortable.

“You stay in your home environment. That’s our goal, to make you as comfortable and pain free as possible. It’s really about continuing to live at home,” said Anita Todd, community relations manager at Coastal Hospice.

“When I talk to patients, they are still doing things they enjoy. Would you rather have quality, compassionate care at end of life or aggressive treatment? You’re still alive, so let’s focus on life,” she said.

“There is a point in time when treatment isn’t going to help any more,” said Cowall, who urges advanced directives that stipulate wishes for health care.

“Hospice treats symptoms so hospice is treatment. It’s not just doing nothing. Hospice is medical care. It is an equal player. The idea is to change community perception,” Cowall said.

“If you die you need an undertaker,” he said. “Hospice is about life.”