My lab coat proudly showing my MDiv
Moffitt Cancer Center
University of South Florida Fellowship in
Hospice and Palliative Care
August 31, 2013
Month two of my fellowship is now history. I continue to learn about this new specialty as well as new insights into the manner in which I will adapt my own unique interests and vision. This month’s rotation has taken me to the Moffitt Cancer Center.
The Moffitt Cancer Center is a not for profit hospital solely conceived and operated to address the diagnosis, treatment, and prevention of cancer. As a result of this very narrowly focused disease orientation, it attracts a very special group of patients. Having been designated as a National Cancer Institute Comprehensive Cancer Center in 1986, a great deal of research money has helped fund a number of innovative programs. It is the Southeast’s largest bone marrow transplant center, for instance. Last year there were 9216 admissions and 328,000 outpatient visits to the 206-bed facility.
The narrow specialty focus tends to skew the type of “average” patient in the institution. It tends to be a hospital of last resort for many patients with unusual cancers as well as many who have failed all conventional therapies. As a consequence, the patients tend to be very ill. Patients undergoing bone marrow transplantation can come incredibly ill due to a paralyzed immune system. Patients who have bone marrow transplantation for leukemia, for example, have already had a series of incredibly challenging treatments before they even reach the transplantation stage. It’s obvious that this patient population would be a fertile area for a variety of research projects that explore faith and hope in the context of serious illness.
As I have mentioned before, this fellowship is in the area of palliative care and hospice. I described an inpatient hospice unit in my reflection on month #1. A hospital setting lends itself much more to issues of palliation. Here is a definition of palliative care:
Palliative care means patient and family centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.
It would be easy to write volumes just about this definition, but I think what’s really important is the centered care emphasis that includes patient and family and touches on the many elements listed as primarily focused on suffering. This concept is successfully operational in many institutions. However, at Moffitt Cancer Center palliative care does not have a strong foothold. Functioning as a tertiary referral center where very experimental phase I drug trials are commonly employed, the hospital is so focused on “battling” cancer that many patients have only a very short survival time between the failure of the most recent experimental therapy and the end of their lives. As a consequence the time required to address all the emotional, social, and spiritual aspects of end of life care simply doesn’t exist. I write this not as a blazing critique of Moffitt but rather the reality of how medicine is practiced at a research institution.
What I have really learned during this month at Moffitt is how to effectively use narcotics to control pain. Cancer patients have a great deal of pain, and surveys commonly show that most people have great concern about experiencing severe pain associated with advanced illness. I have learned to recognize those situations that call for large doses of narcotics and have become adept at switching between drugs to gain efficacy or administer the drugs through a continuous intravenous pump when urgent pain control is needed. My experience has taught me that there should never be a time when a patient suffers for extreme pain. There are effective drugs that can be given in very safe ways to eliminate this fear from peoples’ minds.
My own personal challenge at a place like Moffitt is how to introduce the idea to my patients that I have an interest and training to engage them as persons in a way that transcends their particular physical illness. How do I tactfully introduce my concern about their spiritual life, the meaning of their illness, and their relationship to a power greater than themselves? I need to know about what community they have to relate to whether it is religious or secular. And how do I continue to combine my duties as physician and spiritually focused friend through a serious illness? I believe these answers will become more obvious during my rotation at Tampa General Hospital that begins in October.
On Friday afternoons I take on a very different role from a physician in training to preceptor in medicine for third year medical students. I feel very privileged to have been invited to participate in this class that addresses more unique patient populations that doctors are likely to experience. The course has formal lectures, standardized patient evaluations, and small group discussions and reflections. There is a strong narrative component. Having met the several members of the education faculty when I visited in January, I expressed my desire to be involved with physician formation. I define the latter as a system designed to foster a life long commitment to compassion and values based care.
Standardized patients are “actors” who volunteer to participate in the teaching process. One patient was deaf who brought an interpreter. Another man, a quadriplegic in a wheelchair, helped the students learn techniques for examining a patient with a shoulder complaint who is disabled. The student takes and history and examines the patient as I observe through one-way glass. At the end of the time allowed, I then offer a critique of his/her approach to the patient, and then the professional patient makes some observations. It is a great learning experience. In addition, the students watched a movie entitled Murderball about a group of wheelchair rugby athletes and their camaraderie around a team sport. This gave me an opportunity to point out the importance of community as a way to support one another. The emphasis on community at Duke Divinity School clearly shows through.
I will fill a pulpit for the first time as a Duke graduate on September 1 at the Seminole Heights United Methodist Church. The pastor, Matt Horan, was the associate pastor at Hyde Park UMC, our home church, until this June when he was appointed to his own church. He had planned a two-part series on dying and death and has invited me to give the first week’s sermon on advance care planning and issues when approaching end of life. I am greatly looking forward to the opportunity. If interested, I’d be very pleased to share a written copy if you desire. Drop me an email, and I’ll send it along.
Joanie is using her Stephen Minister skills in caring for several older folks here in Tampa that we’ve known for years and are now experiencing special needs as their health declines. She is working a few hours a week for a home care agency run by a woman in our church. She is making great contributions.
In September I rotate on to the James A Haley VA Hospital. This will give me another varied experience in an entirely different patient population. In 30 days I’ll have another reflection.
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