Palliation in the age of chronic disease.

Sixty-one-year-old AT has recently been confined to a wheelchair by progressive osteoarthritis in his right hip, which causes him considerable pain. Formerly an active individual--an avid walker and weekend sailor--AT is equally distressed by his lack of mobility and loss of independence. A hip replacement, for which his insurance company would pay, would relieve his pain, increase his mobility, and significantly improve the quality of his life. He has thus decided to proceed with elective surgery. AT considered himself in excellent health except for the degenerative joint disease, which has recently decreased his stamina. He was therefore surprised to learn that a preoperative blood count suggested he had chronic lymphocytic leukemia (CLL) and associated moderate anemia. A thorough workup confirmed the diagnosis of Stage III CLL, which is associated with a life expectancy of approximately twelve to forty-two months. AT's physicians can correct his anemia with periodic blood transfusions and believe that his CLL poses no significant acute contraindication to the proposed surgery. Would hip replacement be considered inappropriate therapy for AT? What are the limits of palliation in the age of chronic disease? At first glance this case is just a little too easy. Despite his shortened life expectancy, it's hard to imagine anyone would wilfully deprive AT of a hip replacement that would reduce his pain and improve the quality of his life. But lurking just beneath the surface of this easy entitlement is a question about how far we should go in pursuit of palliation. A seventeenth-century usage of palliation is "to cloak or disguise." Surgery does exactly that in AT's case: hip replacement will allow this otherwise terminally ill patient a surgical veneer so that he may pursue his previous life for a short time. For a year or perhaps two he will again be independent and without chronic pain, yet a chronic and progressive illness will inevitably bring death. In light of this, is surgery a deceptive cloak--or one that provides warmth and new life? The traditional view, which made this case seem so simple, is that AT's surgery is cut from cloth of the lifegiving sort. As physicians we have always wanted to cheat death and turn back the clock one moment at a time. It would be counter to our historical nature to see AT's surgery as anything but life-promoting. One can imagine a gleeful physician watch his rehabilitated patient walk without pain and hear once more of AT's weekend sailing exploits. At the heart of such a physician-patient celebration is the briefly suppressed knowledge that this is their last victory before the final battle with leukemia. Given the surgery's success, both can willingly suspend disbelief and momentarily embrace the idea of a "cure." This sort of deception can continue as long as AT remains relatively asymptomatic from his leukemia. It persists because both physician and patient have a stake in their final victory together. Under the cloak of such benevolent collusion a physician may fail to recognize that even technically successful surgery may not win the penultimate battle for a patient's life. If circumstances dictate that the pain relief and independence sought through surgery will be rapidly overtaken by a progressive leukemia, then despite its feasibility surgery might be injurious. The injury comes not from a failed hip replacement but rather from a failure to meet a patient's inflated preoperative expectations. Confronted with the facts of this case it would be all too easy to see the surgery as therapeutic and fail to appreciate that it may ultimately be palliative in nature. When healing or making whole are even remotely or briefly within reach surgery seems appropriate. But when it is generously offered in the context of irremediable illness, the largess of the offer is misleading and evasive. The distinction that should guide our understanding of AT's case then is whether surgery can achieve therapeutic or palliative goals. …