What should medicine

He tries to be scientific about decisions. The data show that, after failure of second-line chemotherapy, lung-cancer patients rarely get any added survival time from further treatments and often suffer significant side effects. But he, too, has his hopes.

But, he went on, there were also experimental therapies. He told them about several that were under trial. Sara and her family instantly pinned their hopes on it. The drug was only in a Phase I trial—that is, a trial designed to determine the toxicity of a range of doses, not whether the drug worked.

Furthermore, a test of the drug against her cancer cells in a petri dish showed no effect. The critical problem was that the rules of the trial excluded Sara because of the pulmonary embolism she had developed that summer. To enroll, she would need to wait two months, in order to get far enough past the episode. In the meantime, he suggested trying another conventional chemotherapy, called Navelbine.

Sara began the treatment the Monday after Thanksgiving. Step by step, Sara ended up on a fourth round of chemotherapy, one with a minuscule likelihood of altering the course of her disease and a great likelihood of causing debilitating side effects.

An opportunity to prepare for the inevitable was forgone. And it all happened because of an assuredly normal circumstance: a patient and family unready to confront the reality of her disease. I asked Marcoux what he hopes to accomplish for terminal lung-cancer patients when they first come to see him. For me, the long tail for a patient like her is three to four years.

You hear that time and time again. First, our own views may be unrealistic. A study led by the Harvard researcher Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive, and then followed the patients. Sixty-three per cent of doctors overestimated survival time. Just seventeen per cent underestimated it.

The average estimate was five hundred and thirty per cent too high. And, the better the doctors knew their patients, the more likely they were to err. Second, we often avoid voicing even these sentiments. Studies find that although doctors usually tell patients when a cancer is not curable, most are reluctant to give a specific prognosis, even when pressed.

More than forty per cent of oncologists report offering treatments that they believe are unlikely to work. You worry far more about being overly pessimistic than you do about being overly optimistic. And talking about dying is enormously fraught. When you have a patient like Sara Monopoli, the last thing you want to do is grapple with the truth.

I was, too. Earlier that summer, a PET scan had revealed that, in addition to her lung cancer, she also had thyroid cancer, which had spread to the lymph nodes of her neck, and I was called in to decide whether to operate. This second, unrelated cancer was in fact operable. But thyroid cancers take years to become lethal.

Her lung cancer would almost certainly end her life long before her thyroid cancer caused any trouble. Given the extent of the surgery that would have been required, and the potential complications, the best course was to do nothing.

But explaining my reasoning to Sara meant confronting the mortality of her lung cancer, something that I felt ill prepared to do.

Sitting in my clinic, Sara did not seem discouraged by the discovery of this second cancer. She seemed determined. So she was geared up, eager to discuss when to operate. And I found myself swept along by her optimism. Suppose I was wrong, I wondered, and she proved to be that miracle patient who survived metastatic lung cancer? My solution was to avoid the subject altogether.

I told Sara that the thyroid cancer was slow-growing and treatable. The priority was her lung cancer, I said. We could monitor the thyroid cancer and plan surgery in a few months. I saw her every six weeks, and noted her physical decline from one visit to the next. Yet, even in a wheelchair, Sara would always arrive smiling, makeup on and bangs bobby-pinned out of her eyes.

She was ready to try anything, and I found myself focussing on the news about experimental therapies for her lung cancer.

After one of her chemotherapies seemed to shrink the thyroid cancer slightly, I even raised with her the possibility that an experimental therapy could work against both her cancers, which was sheer fantasy. Discussing a fantasy was easier—less emotional, less explosive, less prone to misunderstanding—than discussing what was happening before my eyes. Between the lung cancer and the chemo, Sara became steadily sicker. She slept most of the time and could do little out of the house. Clinic notes from December describe shortness of breath, dry heaves, coughing up blood, severe fatigue.

In addition to the drainage tubes in her chest, she required needle-drainage procedures in her abdomen every week or two to relieve the severe pressure from the litres of fluid that the cancer was producing there. A CT scan in December showed that the lung cancer was spreading through her spine, liver, and lungs. When we met in January, she could move only slowly and uncomfortably.

Her lower body had become swollen. By the first week of February, she needed oxygen at home to breathe. She just needed one more set of scans for clearance. These revealed that the cancer had spread to her brain, with at least nine metastatic growths across both hemispheres. The experimental drug was not designed to cross the blood-brain barrier. PF was not going to work.

And still Sara, her family, and her medical team remained in battle mode. Within twenty-four hours, Sara was scheduled to see a radiation oncologist for whole-brain radiation to try to reduce the metastases. On February 12th, she completed five days of radiation treatment, which left her immeasurably fatigued, barely able get out of bed.

She ate almost nothing. She weighed twenty-five pounds less than she had in the fall. She confessed to Rich that, for the past two months, she had experienced double vision and was unable to feel her hands.

She was given two weeks to recover her strength after the radiation. Then she would be put on another experimental drug from a small biotech company. She was scheduled to start on February 25th. Her chances were rapidly dwindling. But who was to say they were zero? He went to a medical library when he got the diagnosis and pulled out the latest scientific articles on the disease. The news was devastating. But then he began looking at the graphs of the patient-survival curves.

What the naturalist saw was remarkable variation. The patients were not clustered around the median survival but, instead, fanned out in both directions. Moreover, the curve was skewed to the right, with a long tail, however slender, of patients who lived many years longer than the eight-month median. This is where he found solace. He could imagine himself surviving far out in that long tail.

And he did. Following surgery and experimental chemotherapy, he lived twenty more years before dying, in , at the age of sixty, from a lung cancer that was unrelated to his original disease.

For most situations, however, I prefer the more martial view that death is the ultimate enemy—and I find nothing reproachable in those who rage mightily against the dying of the light. I think of Gould and his essay every time I have a patient with a terminal illness. There is almost always a long tail of possibility, however thin. Hope is not a plan, but hope is our plan.

For Sara, there would be no miraculous recovery, and, when the end approached, neither she nor her family was prepared. On the morning of Friday, February 22nd, three days before she was to start her new round of chemo, Rich awoke to find his wife sitting upright beside him, pitched forward on her arms, eyes wide, struggling for air. She was gray, breathing fast, her body heaving with each open-mouthed gasp. She looked as if she were drowning. He tried turning up the oxygen in her nasal tubing, but she got no better.

He had no emergency kit in the refrigerator. No hospice nurse to call. And how was he to know whether this new development was fixable? When he asked if they should drive, she shook her head, so he called , and told her mother, Dawn, who was in the next room, what was going on.

A few minutes later, firemen swarmed up the stairs to her bedroom, sirens wailing outside. As they lifted Sara into the ambulance on a stretcher, Dawn came out in tears. This was just another trip to the hospital, he said to himself.

The doctors would figure this out. At the hospital, Sara was diagnosed with pneumonia. In another way, the diagnosis of pneumonia was reassuring, because it was just an infection. It could be treated. The medical team started Sara on intravenous antibiotics and high-flow oxygen through a mask. The family gathered at her bedside, hoping for the antibiotics to work.

This could be reversible, they told one another. But that night and the next morning her breathing only grew more labored. Only later did the family realize that those were the last words they would ever hear from her. After that, she began to drift in and out of consciousness. The medical team had only one option left: to put her on a ventilator.

Sara was a fighter, right? And the next step for fighters was to escalate to intensive care. This is a modern tragedy, replayed millions of times over. When there is no way of knowing exactly how long our skeins will run—and when we imagine ourselves to have much more time than we do—our every impulse is to fight, to die with chemo in our veins or a tube in our throats or fresh sutures in our flesh. The fact that we may be shortening or worsening the time we have left hardly seems to register.

We imagine that we can wait until the doctors tell us that there is nothing more they can do. But rarely is there nothing more that doctors can do. We want these choices. Instead, most often, we make no choice at all. We fall back on the default, and the default is: Do Something. Is there any way out of this? In late , executives at Aetna, the insurance company, started an experiment. They knew that only a small percentage of the terminally ill ever halted efforts at curative treatment and enrolled in hospice, and that, when they did, it was usually not until the very end.

So Aetna decided to let a group of policyholders with a life expectancy of less than a year receive hospice services without forgoing other treatments. A patient like Sara Monopoli could continue to try chemotherapy and radiation, and go to the hospital when she wished—but also have a hospice team at home focussing on what she needed for the best possible life now and for that morning when she might wake up unable to breathe.

The surprising result was that they did give up things. They visited the emergency room almost half as often as the control patients did. Their use of hospitals and I. Over-all costs fell by almost a quarter. Aetna ran a more modest concurrent-care program for a broader group of terminally ill patients.

For these patients, the traditional hospice rules applied—in order to qualify for home hospice, they had to give up attempts at curative treatment. But, either way, they received phone calls from palliative-care nurses who offered to check in regularly and help them find services for anything from pain control to making out a living will.

For these patients, too, hospice enrollment jumped to seventy per cent, and their use of hospital services dropped sharply. Among elderly patients, use of intensive-care units fell by more than eighty-five per cent.

Satisfaction scores went way up. What was going on here? And somehow that was enough—just talking. The explanation strains credibility, but evidence for it has grown in recent years. Two-thirds of the terminal-cancer patients in the Coping with Cancer study reported having had no discussion with their doctors about their goals for end-of-life care, despite being, on average, just four months from death.

But the third who did were far less likely to undergo cardiopulmonary resuscitation or be put on a ventilator or end up in an intensive-care unit. Two-thirds enrolled in hospice. These patients suffered less, were physically more capable, and were better able, for a longer period, to interact with others.

Moreover, six months after the patients died their family members were much less likely to experience persistent major depression. In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation, and to spare their family anguish. Can mere discussions really do so much? Consider the case of La Crosse, Wisconsin. Its elderly residents have unusually low end-of-life hospital costs. Despite average rates of obesity and smoking, their life expectancy outpaces the national mean by a year.

I spoke to Dr. In most respects, the patients were like those found in any I. There was a young woman with multiple organ failure from a devastating case of pneumonia, a man in his mid-sixties with a ruptured colon that had caused a rampaging infection and a heart attack. Yet these patients were completely different from those in other I. To understand La Crosse, Thompson said, you had to go back to , when local medical leaders headed a systematic campaign to get physicians and patients to discuss end-of-life wishes.

Within a few years, it became routine for all patients admitted to a hospital, nursing home, or assisted-living facility to complete a multiple-choice form that boiled down to four crucial questions. At this moment in your life, the form asked:.

By , eighty-five per cent of La Crosse residents who died had written advanced directives, up from fifteen per cent, and doctors almost always knew of and followed the instructions.

Having this system in place, Thompson said, has made his job vastly easier. It was that simple—and that complicated. One Saturday morning last winter, I met with a woman I had operated on the night before. She had been undergoing a procedure for the removal of an ovarian cyst when the gynecologist who was operating on her discovered that she had metastatic colon cancer.

I was summoned, as a general surgeon, to see what could be done. I removed a section of her colon that had a large cancerous mass, but the cancer had already spread widely. I had not been able to get it all. Now I introduced myself. She said a resident had told her that a tumor was found and part of her colon had been excised. Yes, I said. So when she asked me to tell her more about the cancer, I explained that it had spread not only to her ovaries but also to her lymph nodes.

I said that it had not been possible to remove all the disease. She absorbed the news in silence, looking down at the blankets drawn over her mutinous body. Then she looked up at me.

A few days later, I tried again. The most common anti-diarrhoea medicine is loperamide , sold under the names Imodium, Arret and Diasorb, among others. It works by slowing down the action of your digestive system. Do not give anti-diarrhoea medicines to children under 12 as they may have undesirable side effects.

Speak to a GP or pharmacist for advice about a child with these symptoms. If you have stomach ache or heartburn , medicine called antacid will reduce stomach acidity and bring relief. Antacids come as chewable tablets, tablets that dissolve in water, or in liquid form. Keep a sun lotion of at least factor Even fairly brief exposure to the sun can cause sunburn and increase your risk of skin cancer.

Ensure your suncreen provides UVA protection. You can also protect yourself against the sun by wearing a hat and sunglasses, and by avoiding the sun during the hottest part of the day between 11am and 3pm.

A well-prepared first aid kit can help treat minor cuts, sprains and bruises, and reduce the risk of cuts becoming infected. Remember that a pharmacist can also help with many health conditions, such as coughs , colds , asthma , eczema , hay fever and period pain.

They can give advice or, where appropriate, medicines that can help clear up the problem. Instead of booking an appointment with a GP, you can see a pharmacist any time — just walk in. Learn more about how a pharmacist can help with treating common conditions.

Find your local pharmacy. Page last reviewed: 14 April Next review due: 14 April Your medicine cabinet - Healthy body Secondary navigation Body Bones Food for healthy bones Keep bones healthy over 65 Are you at risk of falling? Foot problems and the podiatrist Looking after your feet with diabetes How to stop smelly feet. Lower your cholesterol Keeping your kidneys healthy Top 10 healthy heart tips. But some medicines wouldn't work if the stomach's digestive juices broke them down. For example, insulin is given as a shot under the skin and then it can be absorbed into the bloodstream.

Other medicines would take too long to work if they were swallowed. When you get an IV in the hospital the medicine gets into your blood quickly. Other medicines need to be breathed into the lungs where they work best for lung problems, like some of the medicines used to treat asthma.

Still others work best when they are put directly on the spot that needs the medicine — like patting ointment on an infected cut or dropping ear drops into a clogged-up ear. So medicines sound like a pretty good thing, right? In many cases they are — as long as they are used correctly. Too much of a medicine can be harmful, and old or outdated medicines may not work or can make people sick. Taking the wrong medicine or medicine prescribed for someone else is also very bad news.

You should always follow your doctor's instructions for taking medicine — especially for how long. If your doctor says to take medicine for 10 days, take it for the whole time, even if you start to feel better sooner. Those medicines need time to finish the job and make you better! Larger text size Large text size Regular text size. Let's find out. A Rainbow of Medicine One medicine might be a pink liquid, another medicine might come in a special mist, another might be a blue pill, and still another might come out of a yellow tube.

Medicines Can Replace What's Missing Sometimes a part of the body can't make enough of a certain substance, and this can make a person sick. Medicines Help in Many Ways People take medicines to fight illness, to feel better when they're sick, and to keep from getting sick in the first place. P Pain Relievers and Symptom Soothers But while the antibiotic is starting to fight the bacteria, you might still feel achy and hot, so the doctor might tell your parent to also give you a pain reliever.