Web Extra: Interview with Victor Vogel, MD
Mar 12, 2015 12:35PM
● By Erica Shames
What are the benefits of coming to terms with death?
What I used to tell the medical oncology fellows that I taught in Pittsburgh: it’s liberating. If you get yourself right with – okay, we’re not always going to be successful; some of my patients aren’t going to do well; but what do I think about that. What do I think about life, death, suffering, forgiveness? If you get all those things straight, then as a provider – and also as a human being – you’re liberated because you don’t worry about it. And then you don’t have these unfortunate family convocations at the foot of the dying mom that ask, what do we do? Because they’ve never thought about it, they’ve never discussed it, they don’t know what mom wants, they don’t know what her wishes are, and then you try to resolve all sorts of things through medicine. And, as I say in the book, medical therapy is not very good family therapy. So people need to wrestle with this; the sooner and the younger you wrestle with this, the better off you are.
What skills are necessary to die with hope?
As I say in the book, the Christian answer and perhaps the Jewish answer should be relatively straightforward: God made us, God loves us and God will take care of us, now and in the afterlife. For people of faith, that’s easy. I also recognize there’s a lot of people who don’t share that kind of faith and doubt is fine. The argument I make to those people is an objective one: if you believe that when you die you die and that’s the end, then there’s nothing to worry about. The other argument is this notion: for people of faith, if they believe they are taken care of after death, it should be easier for them to say, we don’t want to do unnecessary treatments. But the logical objective argument is the argument I make in regard to medical futility: we should not do things that are ethically and morally and objectively indefensible. If things don’t improve outcomes, we should stop doing them.
Where does the false hope spring from?
We have a large number of people whose hope is in technology. But that’s what I refer to as suffering hope because ultimately, technology has to fail. It must fail for everyone eventually. So even if you have no faith system, no belief system, I would hope that the objective nonbeliever would say it doesn’t’ make a lot of sense to do things that have no benefit to the outcome. Believe me, I was a little reluctant to put any religious reference in the book. But people would ask, well what’s your ethical point, what’s your moral foundation. Now, I tried very hard to say I’m not trying to say this has to be everyone’s moral foundation—I’m just telling you what I think and how I got to this. Everyone has to figure out what they believe about these things. And how does that get me to making more rational and objective decisions. I don’t preach to people – I’m not trying to convert people. I’m not an evangelist – I’m a doctor! But I have to have some moral and ethical foundation, and I didn’t think I could write a book like this without laying that out.
Does technology take a front seat becaue it’s easier to trust it? If so, how do we get past that?
Chemotherapy is a lot easier than hand-holding. Many patients and their families delegate that; it’s too painful for us to deal with it, let’s just let the doctors do it. Some of that may be denial, some of it may be false hope. But I really do think we’ve abrogated our caring response and we’ve institutionalized it. One of my favorite books of all time is Faulkner’s, as I lay dying. It’s the story of a woman in the 19th century who died, and it was in the American plains, and they had to take her body to her homeplace so she could be buried in her family cemetery. This whole process of taking her on a horse-drawn cart through many miles was a revelation. It showed how in the 19th century death was very proximate; we use to deal with it in the family parlor. We’d put black bunting on the front railing so the community would know the household was grieving. We’ve done away with all that; we’ve institutionalized that. We have a couple of generations of Americans how have no familiarity with death and literally don’t know what to say or do when in the presence of someone who is sick or suffering or dying. We have to change that. Instead of doing that, we have these technical solutions, which aren’t really solutions at all. They’re covering over and relieving us falsely, temporarily from this obligation we have to minister to people who are dying. That’s not just physicians, that’s families.
What are you doing personally to change this dynamic?
It’s a brief time that patients spend in palliative care in hospice – we’re trying to improve that. I’m trying to advocate to my colleagues that early involvement with palliative medicine is a very important thing. It’s one of the first things I did when I came here in 2010. There had been a rift between palliative care and the cancer service line and I brought them back together. And we got palliative medicine practitioners to come to the Knapper clinic to see patients there. We’re constantly trying to bring this awareness that this is something we need to do. Now I do try to do that largely by example, but whenever I have the opportunity to advocate that this is a situation where palliative medicine is a better option, I do. There are data that say, when you go past third-line therapy for many advanced malignancies, it’s just not effective. There are published studies that show people who get palliative care often survive longer than people who get care of the curative kind. We try to constantly remind people of that, and we try to bring the palliative medicine folks closer into what we do here. But it’s a struggle – the orientation of American medicine is cure, cure, cure, treat, treat, treat. It’s going to be a battle. But I think this bolus of aging boomers is going to be the tipping point. As more and more boomers age, this is going to become a pressing issue. We’re going to have to provide better nursing care, better in home hospice . It’s going to come out of necessity. I would have hoped we would have done it because it’s the right thing to do, but I think now we’re going to be pushed into it because we don’t have any choice and we are running out of resources. I have treatments now that single doses of a drug cost as much as $200000 for cancer patients. And these are drugs that won’t cure people; these are drugs that will only extend life by days or weeks.