Un día en la vida de un médico de hospicio
Steven P. Kanner, MD, spent 38 years as an oncologist, helping his patients fight off deadly cancers; today he helps cancer patients and others with life-limiting illness face impending death. As a hospice physician with VITAS Healthcare, Dr. Kanner's job is not to cure his patients but to ensure they spend their last days, months or years in comfort.
Laughter: The Best Medicine
To know Dr. Kanner is to laugh with him. He's always ready with a joke or a teasing remark. When Dr. Kanner enters a patient's home, he brings with him a smile that never quits and a sparkle in his eyes. His easygoing manner puts patients and family members at ease. And it's not hard to see that the enfermeros, aides, trabajador social, capellanes and others on his team enjoy the good-natured bantering he encourages.
Looking for a rewarding career? Be a hospice physician
But when he’s making sure his patients are comfortable and that their cuidadores are getting the support they need, he’s all business.
Hospice physicians have the flexibility to spend as much time with each patient as they need.
"I get to see my patients in their home, which is what I prefer," he says. "I get to see them in their own environment-at home, in bed, with their family around. I feel strongly that there is no good reason for having someone with advanced disease in a hospital environment if they don't need to be. It is always preferable for these patients to be at home."
Partnering with Caregivers
Dr. Kanner generally has about 60 patients under his care. He visits patients on a monthly basis unless they are on cuidado continuo, in which case he sees them more often. On a typical day, Dr. Kanner visits seven to ten patients.
On this day, his first visit is with 86-year-old Diane (names of patients have been changed for privacy), who has advanced COPD. After washing his hands, he goes to the bedside and greets Diane, who is sleeping. She is on oxygen; he carefully puts the end of the stethoscope to her chest and listens. He asks the caregiver, "How's she doing today?"
While the caregiver reports on Diane's sleeping, eating and bowel frequency, Dr. Kanner removes a portable blood pressure machine from his traveling medical case. As he gently slips the cuff around Diane's arm, he explains what he is doing. He checks for pressure ulcers on her hips and heels. The caregiver helps him lift Diane ever so slightly so he can place the stethoscope on her back to listen. He concentrates on her breathing, because altered patterns of breathing are a clue to how the patient is doing.
He will perform this routine checkup on every patient he sees today. Afterward, he will sit with each of their caregivers and go over the patient's medications. He will listen intently as the caregivers tell him what they think the patient needs, and he will learn how those caregivers are holding up.
“Looking at the patient’s chart is important, but caregivers really tell me what’s going on,” Dr. Kanner says.
Managing Unrealistic Expectations
Inside the cozy, book-lined den of the next patient's home is a hospital bed, where 68-year-old Frank lies quietly. Frank's brain cancer has left him paralyzed on one side, and he suffers from altered mental status. Because he is in pain and needs injections, Frank is on continuous care with round-the-clock hospice nurses. Continuous care is only temporary, however, and Dr. Kanner has come to determine when Frank should begin routine home care—when Frank’s wife will become the primary caregiver, with members of the hospice team offering care and support during the week.
"The criteria for continuous care is pain, shortness of breath or uncontrolled symptoms, with the patient needing someone to do things that an able-bodied family member or aide can't do," Dr. Kanner explains. "One of the biggest challenges of my job is dealing with unrealistic expectations, mostly those of the family.
“When a patient is receiving continuous care, the family may think this is going to be ongoing for the life of the patient—but it’s not.”
This is the case with Frank's wife, Cassandra. She is a petite woman who asks the doctor, "Why does the continuous care have to end?" She's worried she won't be able to lift her husband-a sizeable man-turn him over or change his adult diapers. Dr. Kanner explains that soon Frank won't need continuous care because his pain and symptoms will be under control.
He suggests hiring someone to help her, especially at night so Cassandra can get plenty of sleep, but she is concerned about the expense. Dr. Kanner says he will have the hospice team social worker help find someone she can afford. "You have to look out for your own health as well," he says.
Los pacientes y sus familias son lo primero
After filling out a case sheet and slipping it into Frank's chart, Dr. Kanner leaves. As he travels to and from his patients' homes, it's not uncommon to get calls from the nurses on his team. One such call comes in now. The hospice nurse informs him that her patient is close to death and [the nurse or the patient?] would like the doctor to stop by.
Inside the high-rise assisted living facility, Dr. Kanner greets the nurse and goes to check on 96-year-old Thelma, asleep in a hospital bed in the living room. She is on oxygen and breathing rapidly. "We're looking at a very short time here," he says after taking her blood pressure and listening to her heart and breathing.
The nurse is concerned that Thelma is experiencing pain, so Dr. Kanner prescribes the smallest amount of morphine possible to ensure she is comfortable. Since he doesn't want Thelma to be alone and worries that the pharmacy will not deliver the medication quickly, he tells the nurse he will pick it up and bring it to the patient.
“Not many doctors would go get a patient’s medicine,” says the nurse.
After returning with the medication, Dr. Kanner banters with the nurse in her native French. He speaks eight languages: Spanish, Italian, Portuguese, French, Russian, German and Haitian/Creole. This comes in handy as a hospice physician in multi-cultural Miami, Florida.
Ensuring a “Good” Death
Dr. Kanner graduated from Howard University in Washington, DC. He earned his medical degree from Franklin & Marshall College in Lancaster, PA. He completed his residency and internship at Jackson Memorial Hospital through the University of Miami. After spending two years at the National Cancer Institute in Maryland, he opened a private oncology practice in 1972.
In 1987, while still in private practice, he joined VITAS on a part-time basis. After retiring from private practice in 2011, Dr. Kanner became a full-time hospice physician in the VITAS Hollywood, FL, office. He is also the Florida medical director of Palliative Medical Associates, a division of VITAS Healthcare.
Doctors study long hours and spend years in training to learn how to treat illnesses and cure diseases. Many are hardwired to think in terms of curing a patient, whatever it takes. So why would a doctor choose to become a hospice physician, with its focus on comfort instead of cure?
"Hospice is a natural extension of oncology for me," Dr. Kanner explains. "I have always thought that the most important thing was to provide cuidado paliativo to my patients, to make their lives more comfortable. I would tell anyone interested in becoming a hospice physician that they have to have the right mindset. This is comfort care, not aggressive care.
"My job is make the end of someone's life comfortable both spiritually and physically. Death is a process everybody on earth has to go through. Everyone deserves to die well. My job is to make sure that happens."