Friday, January 6, 2012

Curative vs. Palliative

Curative care is focused on healing disease.  Palliative care is directed at alleviating symptoms.  We get into trouble as a society (clinically, ethically, and legally) when we confuse the two.
Typically, the discussion of curative vs. palliative methods is reserved for issues related to end-of-life care for terminally ill patients.  This is a critical component of the overarching health care debate in which we’re currently engaged in this country, though it’s a hot-button issue to say the least.  If Social Security is the “third rail” of American politics, end-of-life care is the “third rail” of the health care debate (“death panels” being my own favorite rhetorical lowlight of the past few years.) 
According to the New England Journal of Medicine, approximately 5% of Medicare beneficiaries die each year, though this group consumes 27% of the Medicare budget.  As a society, we’re simply not comfortable with the concept of death.  And while many of us acknowledge the economic impact of acting more rationally with regard to end-of-life care decisions, when those decisions become personal in nature, rationality is tossed aside (understandably so).  Until we decide to grapple with this most intransigent of bio-medical-ethical debates, very little is likely to change. 
The distinction between curative and palliative care, though, is also extremely relevant to the workers’ compensation medical cost management space, albeit for entirely different reasons.  I am consistently shocked at the number of injured workers that believe their chronic opioid therapy (COT) is, in fact, curative.  I have sufficient faith in the medical community to believe that the source of this ignorance is lack of clear and complete communication between provider and patient regarding “curing disease” and “alleviating symptoms” (and not, presumably, from doctors that don’t understand the difference).
COT should be placed in its proper context as merely palliative care that might be necessary to alleviate symptoms, but will never be sufficient, in and of itself, to fix the underlying problem.  I’m the first to acknowledge there are exceptional cases in which COT is indicated, but we’ve seen too many minor low back sprains turn into tolerance, dependence, addiction, hyperalgesia, and a host of other adverse effects of COT for the current clinical approach to be deemed acceptable.
I wish more doctors, when writing the first script (or the fiftieth script) for opioid therapy had the courage to say, “At best, this is only going to make you feel better for a short time.  This is not going to heal your pain.” 
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