Palliative Medicine
New Fellowship Program Trains Physicians to Help Patients Face Incurable Illness
By Michael Jackman
"Sometimes there are worse things than death," states Dr. Christian Furman, director of the University of Louisville's new Palliative Medicine Fellowship. She speaks from her office on the seventh floor of Louisville's Veterans Affairs Medical Center, her brown eyes gazing intently.
Hers is a statement many people might find hard to accept. But she knows what she's talking about. For the past two years, Furman, who graduated from U of L Medical School in 1996 and completed her residency in 1999, has run the VA's four-bed hospice unit as chief of hospice and palliative medicine. So not only is she in charge of training physicians to help patients whose time is running out, she also personally helps ease many patients through their last days.
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Furman says that the need for a local palliative training program is clear. Too often, patients with incurable diseases are treated using "standard protocols" designed for cure. As a result they often undergo painful, difficult and ultimately useless therapies. Further, most specialists are simply not trained to ease the emotional or physical symptoms that accompany the final stages of diseases such as emphysema, cancer, AIDS, congestive heart failure and diabetes.
As a result, many patients are left "suffering in the intensive care unit and no one's really talking to them about their wishes for treatment," Furman says.
Alleviating suffering and finding hopefulness among hopelessness is what palliative medicine, one of the nation's fastest growing specialties, is all about. According to the U.S. National Hospice and Palliative Care Organization, almost 1 million Americans receive palliative care each year and this number is growing at a rate of more than 20 percent a year.
But what's surprising is that a field emphasizing comfort and not cure also helps patients live longer. As an example, Furman mentions a common symptom, shortness of breath.
In such cases, most doctors are trained to use intubation, an uncomfortable and often demoralizing procedure in which a breathing tube is inserted into the airway and the patient is put on a ventilator. But there's a much less invasive and more comfortable solution: morphine.
The fact that morphine controls shortness of breath as well as pain is "one of the tricks you get taught in the fellowship," Furman says.
It was a trick she learned from Dr. Joe Rotella, medical director of Hospice and Palliative Care of Louisville, and co-director of the new program.
"He is our greatest resource," Furman says. "Everything he taught me I'd never heard before." And now she is helping pass along that knowledge.
Furman sums up the life-extending possibilities of palliative treatment with a simple question: "Feel better equals live longer." As for the emotional and spiritual aspects of treatment, "When you control their fear, emotional suffering and pain, (patients) keep that will to live longer."
Partnership To Improve Terminal Care
The day of our interview, Furman has a full schedule. But there's a party at the Bristol Cafe downtown that night she doesn't want to miss. So though it's only 9 a.m. she's already wearing the long white dress she chose for the evening's festivities: celebrating both the first year of the new Palliative Medicine Fellowship Program and the graduation of the first two fellows.
Dr. Mark Pfeifer will also be at the party. The 48-year-old interim dean of U of L's medical school helped start the new Palliative Medicine Fellowship. He's a matter-of-fact professional wearing a white lab coat, blue dress shirt and a tie with small red checks. In his tidy office on the fifth floor of the medical campus' Abell Administration Center he explains that U of L's Palliative Medicine Fellowship--the first in Kentucky--came about because the region's hospices were short of trained physicians.
"There was a need for expertise to educate the medical community in pain management and improved terminal care," he says, adding, "Fellows become experts in these issues."
The program developed as a partnership among U of L, Hospice and Palliative Care of Louisville and the Louisville Veterans Affairs Medical Center. Two fellows will be trained each year. Hospice and the VA are each supporting one fellowship, and U of L is providing program support.
The fellows work as part of a palliative care team, typically consisting of a physician, nurse, social worker and chaplain. In addition to visiting hospice patients, they attend classes.
The program teaches a holistic approach, Pfeifer explains that this includes setting goals with the patient, controlling symptoms, providing home medical equipment if needed, and including family and loved ones in treatment and decision making. Among the tricky conditions fellows learn to treat are breathlessness, nausea, depression, pain and anxiety. They also learn how to communicate in difficult situations, create goals of care, and how to bring up the difficult subject of transitioning from life-prolonging care to comfort-only care.
'No One Dies Alone'
When Dr. Judith Gerharter speaks about her fellowship experience, her gentle lilt harks back to her native Denver. In typical resident fashion, she wears her stethoscope like a necklace, accessorizing tan pants and a pink sweater. Though her origins are on the West Coast, before coming to U of L she was a radiologist in Denver.
It seems an odd but, in hindsight, a logical migration from radiology to palliative care. After training as a bone radiologist, Gerharter found herself giving breast exams.
"I was working is a clinic full time, delivering bad news." She pauses, "I was really good at it." She holds up a laminated card provided by the program--a list of techniques for giving bad news, such as, "First give a warning shot." During her years as a breast interventionist, she says, "I figured it out myself."
Gerharter applied to 15 fellowship programs "that weren't interested in talking to a radiologist." But when U of L responded that it was more important how compassionate she was then what her specialty was, she knew she'd found a match.
One reason she switched to palliative care was her frustration of being in a "cure-centered" profession. "What if you are one of the women who have the gall not to be cured of cancer? We say things like, 'We have nothing to offer.'"
But she learned she has plenty to offer. "I was a calming influence, helping them through something that is so scary." In return she has learned a calming lesson about people's last moments.
"The human spirit talks in metaphors. When people are sick and dying there's all kinds of messages. People say things like, 'Where's my airplane ticket,' 'Did you pack my suitcase?' People start talking about receiving visitors who are no longer living."
As a result of these experiences, Gerharter is convinced that "no one dies alone."
The former radiologist has traveled a long spiritual path from her diagnostic-centered roots. "The high-tech stuff doesn't work out here. There's no X-ray that will show you how many days they have left or how much spirit they have left."
She may have a deep reservoir of compassion, but her new field can still be draining. Gerharter says the palliative approach takes "a lot of energy." The emotional cost of the field is a theme that comes up with other physicians.
Director Furman remembers one case. It was around Christmastime and a young woman was dying of cancer. She was divorced, and had a 3-year-old child.
"She was trying to figure out who was going to take care of the child after she died. There was really no one. No amount of morphine could make her feel better, as she was experiencing 'social pain.'"
With the help of the hospice team, she finally made arrangements and at last found peace. But not Furman, at least not right away. "I cried every day on that rotation, " she says.
Just like families of patients, the palliative care teams need to grieve as well. Furman says they help each other out, and "a bereavement counselor volunteer comes to the weekly meetings to get us in tune with ourselves."
Dr. Ruth Simons, who along with Gerharter was celebrating her graduation that evening, chooses her words carefully. Her blue eyes behind tortoiseshell glasses seem to search for the right phrase.
"You come out (of patient meetings) drained completely," she says. "When you tell families someone is dying, they start screaming and crying."
Asked if she finds this sort of thing depressing, she replied that on the contrary, "I make it a better journey. It's very rewarding."
But to cope with the intense emotions, she walks. In addition, "Chocolate is very healing, I find. And hanging out with my family," that includes her husband, a daughter aged 12 and a son aged 10.
Like Gerharter, Simons' journey to palliative medicine was roundabout. Originally from Canada, she trained there as a speech pathologist in 1985. In 1991, she immigrated to the United States. Deciding to change careers, Simons enrolled in U of L's medical school. She completed an internal medicine residency last year. She first heard about palliative care during that time. And as with Gerharter, the holistic approach is one of the ideas that hooked her.
"In internal medicine the emphasis is on diagnostic tests. In palliative care the emphasis is more on symptom management and communication. You're looking at a very big picture," she says.
Upon completion of her fellowship in May, she was hired by Hospice and Palliative Care of Louisville. She began in August. Already, the new program is fulfilling its mission to provide physicians in the region.
Simons expects her job to extend beyond helping patients. "There's an absolute need to communicate and teach primary care physicians, nurses and other fellows.
The Schiavo Case
No discussion of palliative medicine would be complete without recalling the Terri Schiavo case and what it reveals about the field. Schiavo, a Florida woman, suffered a heart attack in 1990 which resulted in severe brain damage and the need for life support to sustain her in what many physicians had diagnosed as a persistent vegetative state.
Schiavo's husband wanted the right to remove his wife's feeding tube. However, her parents wanted to continue life and hope for recovery. Her fate was fought bitterly through the legal and political systems. This past March, after 15 years, Michael Schiavo won his case. His wife died later that month.
In one sense, she had been receiving palliative care, Pfeifer says. But according to him, the issue became more about politics than medical care, about who gets to decide a person's fate, the social or legal systems. Schiavo's predicament reveals what can happen when patients can't speak for themselves, he says.
During the long, divisive and hostile court battle, Schiavo's husband maintained that removing the feeding tube was what his wife would have wanted. Furman says that's an important part of the palliative care decision-making process.
"You have to ask the family what would the patient say if she could speak for herself. Otherwise, people could make decisions based on their personal issues."
One thing that disturbs Furman about the Schiavo case is that "there never was a palliative care consult done or an ethics committee consulted." It's clearly an example of her view that "sometimes there are worse things than death."
But palliative care teams--by alleviating debilitating symptoms, patient and family fears and dysfunction and helping people make ultimate decisions--do seem to turn death into a friend rather than an enemy. During her fellowship training, Gerharter has experienced this firsthand.
"Death can be a light and joyful subject. There's resistance to accept the fact that time is short and we can't cure you. But in the back of their minds they all know that anyway. Once the resistance is past, there's a chance. Now the whole room lightens. People start laughing, telling stories, making plans. That's a really great part of this."
