Who Should Be Thinking About Seeing a Palliative Physician
Those affected with a serious illness and their loved ones may find care to be stressful. Dr. Lawrence Cosner, Medical Director of Rural Health Clinic, discusses how palliative care works.
Featuring:
Lawrence (Larry) Cosner, MD
Dr. Cosner is an Internal Medicine physician who serves as Medical Director at the RRH Hospice/Home-Health Program and RRH Adult Rural Health Clinic (Interim); he also works very occasionally for Hospitalist program at RRH. He consults as needed to the I.T. department and is one of the co-chairs of the Medical Staff QI Committee. He completed his education in San Diego at UCSD in 1982 and did his residency at the UCSD affiliate, Mercy Hospital in 1985; he spent the following year as Chief Resident and Lecturer at Mercy Hospital and UCSD School of Medicine, coming back to his home town of Ridgecrest in 1986 to practice. Besides direct patient care, his activities since his return have included: past member of Sage Board of Directors; adjunct professor at Cerro Coso Community College; member of the RRH Board of Directors; member of the Board of Directors for the Kern County Medical Society, including 1 year as President; county-elected State Delegate to the CMA; ten years with the RRH IT department, converting to the modern networked computer environment; and immediate-past chairman at the IMQ Hospital Program Survey Committee. He was first elected to the Hospital Corporation in 1988 and his special interests include quality assurance, computers in medicine, and community-wide access to medical care. Transcription:
Prakash Chandran (Host): Living with a serious illness can be very stressful for the affected patient and their loved ones. But did you know that there is a type of treatment that focuses on improving the quality of life for both the patient and their family? It’s called palliative care and today we’re going to learn about it with Dr. Larry Cosner, an Internal Medicine Physician at Ridgecrest Regional Hospital.
This is a podcast from Ridgecrest Regional Hospital. I’m Prakash Chandran. So, first of all Dr. Cosner, let’s talk about what exactly palliative care is.
Lawrence (Larry) Cosner, MD (Guest): So, palliative care is probably best understood in the context of care overall. So, let me take a minute to sort of describe that. On the one end of care are people who have disorders which are completely curable and by curing them can put them back to a completely normal and full and healthy life. And obviously, in that setting, that’s what we want to do. There are then people who have disorders which are not really addressable at all by modern medicine that we know those disorders are going to take the patient’s life and so for such patients; really our priority is to make them comfortable for whatever period of time is left for them here on earth. And we call that hospice care.
Now sandwiched between those two is something that arises occasionally where a patient will have a disorder that is either difficult to treat, or that we can only treat for some period of time, but their quality of life is good enough that they want to extend that time as long as possible. But they also want to extend that time in a setting where their symptoms are as well controlled as possible. So, in that setting, where somebody is dealing with a serious probably life threatening illness that also causes them and often as you pointed out, their family serious symptoms; what we like to be able to do is we like to let some of their specialists concentrate on keeping their disease as well controlled and as well treated as possible but that gives other specialists the opportunity to address their symptoms to make them feel as good as they can in the context of treating their underlying diseases by other specialists. Those doctors are called palliative physicians that are concentrating on making their symptoms well-controlled.
Host: Yeah, I think you described it very, very well and just kind of where palliative care fits on that spectrum. I’m curious as to some of the most common things that palliative care physicians treat.
Dr. Cosner: So, that’s an excellent question. Probably at the top of that list are various cancers or to use the technical term, malignancies. In many cases, modern medicine may lack the ability to completely cure certain cancers, certain malignancies but does have the ability to hold them at bay to either reduce them to not visibly present or at least keep them from going larger for some substantial period of time, months or sometimes even years.
Oftentimes, in that setting, somebody says look, I know this cancer will probably take my life at some point in the future, but at the moment, my specialists are keeping it controlled and I want to be able to live my life as fully as possible. So, let’s let my specialists treat my cancer for now which is being held at bay and I’m going to let my palliative physicians make sure that I feel good enough to do the things I want to do to take that cruise I’ve always wanted to go on or go across the country to see my grandchildren or plant my garden or take care of my dogs or whatever.
Other diseases of course can sometimes do things like that. Serious cardiac heart disease or serious lung disease will sometimes put a person in the same situation but probably the commonest by far are the malignancies, the cancers of various sorts.
Host: Okay. I am curious about when a general oncologist for example turns into a palliative care physician or is there a certain handoff that happens when the family decides that they want to seek palliative care. Maybe talk a little bit about how that dynamic works.
Dr. Cosner: So as a general rule, oncologists are superbly trained to function in both of those modes. They are superbly trained to function in the mode of let’s see if we can cure your malignancy and it’s surprises a lot of people how many malignancies we are able to cure in this day and age versus saying look this malignancy is not one we can cure or this malignancy could have been cured had it been at an earlier stage but it’s too late of a stage so we can’t cure it but we can treat it palliatively. We can treat it to keep it from taking your life at least for some period of time. So, all oncologists that I work with are superb at both of those functions.
The difference is that as a general rule, when you are trying to cure somebody’s disease; you really are a little bit reluctant to focus too much on the symptoms because you are afraid, you’ll lose the opportunity to cure. Whereas once it’s clear to both the oncologist and the patient that this is no longer a disease which is ultimately curable, even if for now you can hold it at bay; at that point, the oncologist often would like to be able to have another provider help them because sometimes the symptom control itself can be just as demanding as trying to treat the underlying malignancy in terms of the time it takes and the complexity. So, at that point, many oncologists will say look I’m an oncologist, I am the specialist who knows how to treat your underlying tumor; so that we don’t short change you in terms of the time it takes to also treat your pain or your fatigue or your itching or whatever it is; let’s also get you to a specialist who can just focus on those symptoms. That’s the palliative doc and we work hand in hand with the oncology people.
Host: Yeah, so this kind of leads me to my next question around when a patient or their loved ones should ask to transition to palliative care. Like is that something that’s immediately recommended to them or is this something that they need to talk to their physician about?
Dr. Cosner: So, many oncologists are already spontaneously going to bring this up with patients especially the oncologists who practice in either academic settings or younger oncologists who have been sort of trained in the model of trying to help patients better understand the disease. But all of us in a busy work day practice and I think especially some of the oncologists who may have trained longer ago and may have been at that point we in medicine were less sensitive to such things; they may not bring it up spontaneously. So, what I tell patients in my general internal medicine practice, what I tell patients is always ask your oncologist at every visit, just ask them as one of the questions you ask, where are we in our goals Doctor. Ask your oncologist that. Are we still in the position where we think we can cure my tumor? Where we can get rid of my tumor and I won’t have to deal with it again or at least I won’t have to deal with it for five or ten years. I mean some period of time which is in biology is as long as pretty much forever. Or are we dealing with my tumor now that you don’t think we can get a cure out of this?
And the oncologist will in my experience, be able to then give the patient that answer. They will say no we’re still hoping for a cure Mr. Smith or no, Mr. Smith, I think because the last two treatments we’ve tried didn’t get rid of your cancer entirely, they kept it at bay but they didn’t get rid of it, I think we have to face that we’re probably no longer looking at a cure but let’s try to keep it minimized as long as we can. That’s the time that palliative care becomes an issue to discuss with your oncologist should I also Doctor, add a palliative specialist to our care.
Host: So, what I’m really hearing from you is that in general, an oncologist will be pretty proactive with you in telling you when you need to make that transition but it’s never a bad idea for you or your loved ones to be proactive and ask the question where are we on our goals, does it make sense to make that transition to palliative care sooner than later. So, speaking of the care itself, I’m sure a lot of us are wondering what that treatment looks like once we start palliative care. So, maybe talk a little bit about that.
Dr. Cosner: Often palliative care revolves around the kind of symptoms that make people less able to live their life or less able to enjoy it. So, pain control is of course a crucial issue and pain control is a more complicated problem nowadays because as almost everyone is aware, we are in the midst of an opioid crisis where we’ve probably we as a profession, we as a society, all of us together have probably overused the opioid pain medications, morphine and codeine and things like that and the street drugs like heroine to the point that the use of those drugs is now very tightly controlled and watched very closely by the government and that has made a lot of providers somewhat more reluctant to do that. So, having a specialist that does nothing but that kind of medicine, i.e. practice using opioids often frees the oncologist or the general internist up from having to worry that they are going to be looked at as over treating any given patient because the government differentiates between treating patients in a palliative practice or a hospice practice versus a general practice.
So, pain control is one of the crucial issues and that’s complicated these days. But many times, it’s also being able to address things like dizziness, dehydration, itching, sleeplessness is a common problem, insomnia, weakness that can be either due to the disease or the treatment or whatever. Those are all symptoms which might be addressed by the palliative care specialist.
Host: You know just as we wrap up here, I imagine that discussing palliative care comes with a certain realization for the patient and their families, so I’m curious as to if you have any advice for people who might be apprehensive about discussing palliative care with their loved ones or for the patients themselves.
Dr. Cosner: My advice to everyone and especially to loved ones who often as you pointed out earlier in our conversation need to be the patient advocate because the patient may feel so bad in some settings that the patient can’t even adequately articulate, can’t talk about how bad they feel. So, having loved ones as part of that team that can talk about those symptoms is important. The loved ones often make conversations about the underlying disease more acceptable and easier to undertake if they remind themselves and if they remind their loved ones that none of us knows what’s going to happen in the future and anything we talk about and anything we plan is not carved in stone. Let’s talk about how to approach things if they don’t go well but let’s keep hoping that things are going to go well. And I emphasize that with all my patients.
Host: Well Dr. Cosner, this has been hugely insightful. I really appreciate your time today. That’s Dr. Larry Cosner, an Internal Medicine Physician at Ridgecrest Regional Hospital. Thanks for checking out this episode of Ridgecrest Regional Hospital Podcast. Head to www.rrh.org/podcast for more information. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll talk next time.
Prakash Chandran (Host): Living with a serious illness can be very stressful for the affected patient and their loved ones. But did you know that there is a type of treatment that focuses on improving the quality of life for both the patient and their family? It’s called palliative care and today we’re going to learn about it with Dr. Larry Cosner, an Internal Medicine Physician at Ridgecrest Regional Hospital.
This is a podcast from Ridgecrest Regional Hospital. I’m Prakash Chandran. So, first of all Dr. Cosner, let’s talk about what exactly palliative care is.
Lawrence (Larry) Cosner, MD (Guest): So, palliative care is probably best understood in the context of care overall. So, let me take a minute to sort of describe that. On the one end of care are people who have disorders which are completely curable and by curing them can put them back to a completely normal and full and healthy life. And obviously, in that setting, that’s what we want to do. There are then people who have disorders which are not really addressable at all by modern medicine that we know those disorders are going to take the patient’s life and so for such patients; really our priority is to make them comfortable for whatever period of time is left for them here on earth. And we call that hospice care.
Now sandwiched between those two is something that arises occasionally where a patient will have a disorder that is either difficult to treat, or that we can only treat for some period of time, but their quality of life is good enough that they want to extend that time as long as possible. But they also want to extend that time in a setting where their symptoms are as well controlled as possible. So, in that setting, where somebody is dealing with a serious probably life threatening illness that also causes them and often as you pointed out, their family serious symptoms; what we like to be able to do is we like to let some of their specialists concentrate on keeping their disease as well controlled and as well treated as possible but that gives other specialists the opportunity to address their symptoms to make them feel as good as they can in the context of treating their underlying diseases by other specialists. Those doctors are called palliative physicians that are concentrating on making their symptoms well-controlled.
Host: Yeah, I think you described it very, very well and just kind of where palliative care fits on that spectrum. I’m curious as to some of the most common things that palliative care physicians treat.
Dr. Cosner: So, that’s an excellent question. Probably at the top of that list are various cancers or to use the technical term, malignancies. In many cases, modern medicine may lack the ability to completely cure certain cancers, certain malignancies but does have the ability to hold them at bay to either reduce them to not visibly present or at least keep them from going larger for some substantial period of time, months or sometimes even years.
Oftentimes, in that setting, somebody says look, I know this cancer will probably take my life at some point in the future, but at the moment, my specialists are keeping it controlled and I want to be able to live my life as fully as possible. So, let’s let my specialists treat my cancer for now which is being held at bay and I’m going to let my palliative physicians make sure that I feel good enough to do the things I want to do to take that cruise I’ve always wanted to go on or go across the country to see my grandchildren or plant my garden or take care of my dogs or whatever.
Other diseases of course can sometimes do things like that. Serious cardiac heart disease or serious lung disease will sometimes put a person in the same situation but probably the commonest by far are the malignancies, the cancers of various sorts.
Host: Okay. I am curious about when a general oncologist for example turns into a palliative care physician or is there a certain handoff that happens when the family decides that they want to seek palliative care. Maybe talk a little bit about how that dynamic works.
Dr. Cosner: So as a general rule, oncologists are superbly trained to function in both of those modes. They are superbly trained to function in the mode of let’s see if we can cure your malignancy and it’s surprises a lot of people how many malignancies we are able to cure in this day and age versus saying look this malignancy is not one we can cure or this malignancy could have been cured had it been at an earlier stage but it’s too late of a stage so we can’t cure it but we can treat it palliatively. We can treat it to keep it from taking your life at least for some period of time. So, all oncologists that I work with are superb at both of those functions.
The difference is that as a general rule, when you are trying to cure somebody’s disease; you really are a little bit reluctant to focus too much on the symptoms because you are afraid, you’ll lose the opportunity to cure. Whereas once it’s clear to both the oncologist and the patient that this is no longer a disease which is ultimately curable, even if for now you can hold it at bay; at that point, the oncologist often would like to be able to have another provider help them because sometimes the symptom control itself can be just as demanding as trying to treat the underlying malignancy in terms of the time it takes and the complexity. So, at that point, many oncologists will say look I’m an oncologist, I am the specialist who knows how to treat your underlying tumor; so that we don’t short change you in terms of the time it takes to also treat your pain or your fatigue or your itching or whatever it is; let’s also get you to a specialist who can just focus on those symptoms. That’s the palliative doc and we work hand in hand with the oncology people.
Host: Yeah, so this kind of leads me to my next question around when a patient or their loved ones should ask to transition to palliative care. Like is that something that’s immediately recommended to them or is this something that they need to talk to their physician about?
Dr. Cosner: So, many oncologists are already spontaneously going to bring this up with patients especially the oncologists who practice in either academic settings or younger oncologists who have been sort of trained in the model of trying to help patients better understand the disease. But all of us in a busy work day practice and I think especially some of the oncologists who may have trained longer ago and may have been at that point we in medicine were less sensitive to such things; they may not bring it up spontaneously. So, what I tell patients in my general internal medicine practice, what I tell patients is always ask your oncologist at every visit, just ask them as one of the questions you ask, where are we in our goals Doctor. Ask your oncologist that. Are we still in the position where we think we can cure my tumor? Where we can get rid of my tumor and I won’t have to deal with it again or at least I won’t have to deal with it for five or ten years. I mean some period of time which is in biology is as long as pretty much forever. Or are we dealing with my tumor now that you don’t think we can get a cure out of this?
And the oncologist will in my experience, be able to then give the patient that answer. They will say no we’re still hoping for a cure Mr. Smith or no, Mr. Smith, I think because the last two treatments we’ve tried didn’t get rid of your cancer entirely, they kept it at bay but they didn’t get rid of it, I think we have to face that we’re probably no longer looking at a cure but let’s try to keep it minimized as long as we can. That’s the time that palliative care becomes an issue to discuss with your oncologist should I also Doctor, add a palliative specialist to our care.
Host: So, what I’m really hearing from you is that in general, an oncologist will be pretty proactive with you in telling you when you need to make that transition but it’s never a bad idea for you or your loved ones to be proactive and ask the question where are we on our goals, does it make sense to make that transition to palliative care sooner than later. So, speaking of the care itself, I’m sure a lot of us are wondering what that treatment looks like once we start palliative care. So, maybe talk a little bit about that.
Dr. Cosner: Often palliative care revolves around the kind of symptoms that make people less able to live their life or less able to enjoy it. So, pain control is of course a crucial issue and pain control is a more complicated problem nowadays because as almost everyone is aware, we are in the midst of an opioid crisis where we’ve probably we as a profession, we as a society, all of us together have probably overused the opioid pain medications, morphine and codeine and things like that and the street drugs like heroine to the point that the use of those drugs is now very tightly controlled and watched very closely by the government and that has made a lot of providers somewhat more reluctant to do that. So, having a specialist that does nothing but that kind of medicine, i.e. practice using opioids often frees the oncologist or the general internist up from having to worry that they are going to be looked at as over treating any given patient because the government differentiates between treating patients in a palliative practice or a hospice practice versus a general practice.
So, pain control is one of the crucial issues and that’s complicated these days. But many times, it’s also being able to address things like dizziness, dehydration, itching, sleeplessness is a common problem, insomnia, weakness that can be either due to the disease or the treatment or whatever. Those are all symptoms which might be addressed by the palliative care specialist.
Host: You know just as we wrap up here, I imagine that discussing palliative care comes with a certain realization for the patient and their families, so I’m curious as to if you have any advice for people who might be apprehensive about discussing palliative care with their loved ones or for the patients themselves.
Dr. Cosner: My advice to everyone and especially to loved ones who often as you pointed out earlier in our conversation need to be the patient advocate because the patient may feel so bad in some settings that the patient can’t even adequately articulate, can’t talk about how bad they feel. So, having loved ones as part of that team that can talk about those symptoms is important. The loved ones often make conversations about the underlying disease more acceptable and easier to undertake if they remind themselves and if they remind their loved ones that none of us knows what’s going to happen in the future and anything we talk about and anything we plan is not carved in stone. Let’s talk about how to approach things if they don’t go well but let’s keep hoping that things are going to go well. And I emphasize that with all my patients.
Host: Well Dr. Cosner, this has been hugely insightful. I really appreciate your time today. That’s Dr. Larry Cosner, an Internal Medicine Physician at Ridgecrest Regional Hospital. Thanks for checking out this episode of Ridgecrest Regional Hospital Podcast. Head to www.rrh.org/podcast for more information. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll talk next time.