Dr. Craig Blinderman, director of Adult Palliative Care Services and co-director of the Center for Supportive Care and Clinical Ethics, teaches in the Masters of Science in Bioethics program at Columbia University. An expert in the field of palliative care, he helps improve the quality of life for patients who may be experiencing a chronic or terminal illness. For the Bioethics program, he guides students through the ethical issues that arise when patients want to withhold or withdraw life-sustaining treatment or to hasten death. Here, we speak with him about palliative care, ethics, and how pain management can sometimes save a patient’s life.
Can you tell me more about palliative care and some of the issues you typically deal with?
With palliative care, we’re engaged in a clinical service here at the hospital that does inpatient and outpatient interdisciplinary palliative care. This is for patients who are not necessarily at the terminal stage but have various unmet palliative needs. They could be related to pain or symptom management or supportive counseling or helping with planning for the future or articulating their goals of care or advanced care planning.
We’re not there just to treat the disease; the benefit may wane over time and may not be consistent with their goals. So when we uncover what a patient’s ultimate goals are in light of their understanding of their prognostic awareness, we help them make better decisions together: maybe avoiding hospitalization or maybe other things that they want to accomplish in their life like attending their grandchild’s graduation. We can keep them outside of a hospital setting and help them improve the quality of their life.
Are there any real-world examples that you can discuss that illustrate some of these major ethical challenges in palliative care?
One example is a patient suffering from advanced pancreatic cancer – and also suffering from what we call existential distress. They feel that their life no longer has meaning or that they’re struggling with the loss of their autonomy and so forth. They want to hasten their death. And you’re confronted with this problem.
In New York state and in many states, it’s illegal – and, I would argue, unethical – to assist patients in dying. So when you’re faced with that, how do you address it? How do you assess what’s going on here?
This is the beginning of the conversation. A person may request that, but that doesn’t mean that’s really what they’re asking for, and that might mean that there’s some psychiatric diagnosis that hasn’t been treated. Perhaps they really need pain management; perhaps if you free them from pain, they will better cope with their condition. So sometimes giving the patient the spectrum of options that are out there can help mitigate their desire to hasten death.
How do you walk your students through these complex issues?
In the Bioethics course, I may be introducing these concepts to students for the first time and helping them think about medical care in a more nuanced way – getting back to patient-centered care and moving away from the idea that just because we can do something doesn’t mean that we should.
How do you teach these concepts in the Bioethics program, where students might not necessarily be medical practitioners?
I use a case-based format. I’ll introduce, for example, a patient who has multisystem organ failure and who is dependent on life support and is unable to make decisions on their own because of changes in their mental status. So we’ll discuss the ethical issues that arise concerning patient autonomy and how to actualize this patient’s goals. How can we use surrogate decision making to decide whether to sustain the patient’s life at this time and whether that’s consistent with their goals?
Sometimes patients and families and care teams don’t see things in the same way. So how do we bring those things together to create the most effective, compassionate, ethical care?