Dr. Pile’s perspective on palliative care and the POST form initiative

Presenter: Emily
Guest: Dr. Christopher Pile
Guest Bio: He is the Chair and Medical Director of the Virginia POST (Physicians Orders for Scope of Treatment) Collaborative Executive Committee, and works for the Good Samaritan Hospice in Roanoke, Virginia.

Segment Overview
Dr. Pile shares his perspective on palliative care and the POST form initiative, including his experiences as a physician discovering palliative care, and his thoughts on how it has transformed his practice.


Health Professional Radio

Emily: You’re listening to Health Professional Radio. This is Emily and I’m speaking with Dr. Christopher Pile. He is the Chair and Medical Director of the Virginia POST Collaborative Executive Committee and he works for the Good Samaritan Hospice in Roanoke, Virginia. Dr. Pile, how are you?

Dr. Christopher Pile:    Doing well today, Emily.  Thanks for having me on.

Emily:    I’m glad to hear it.  We’ve been talking a little bit in our previous segments about what some of the patient experiences and what some of the physicians experience and healthcare provider’s experiences are with the POST collaborative which is the Physician Orders for Scope of Treatment and it allows patients to make their own choices about what their end-of-life care will be.

I’m interested in any stories that you might be able to tell me as far as your own personal experiences.  These could be things that you’ve witnessed or things that you’ve noticed, trends that you’ve noticed, or they could even be your own personal experiences from a standpoint of why you do what it is that you do.  So, anything you’d like to share, I’d love to hear it.

Dr. Pile:    I appreciate that, Emily.  I would say in my experience as a palliative medicine physician, it wasn’t something that I initially knew existed,  especially since my training in 1996 and residency in 1999 in Family Medicine.  It was over a period of my practice as a family physician, treating the whole spectrum of care from … we’d like to say from cradle-to-grave care, that I started to [indecipherable 01:37] the opportunities that existed at the end of life for patients to achieve growth, healing, despite whatever disease state that they were in.

Ultimately, if it was a terminal disease, that they could still transcend that situation both as an individual or as family.  I started to see my ability as a physician to help facilitate that by answering questions, by providing information so they can make informed decisions, and then by providing expert medical care to relieve any signs or symptoms that they may be experiencing.  That’s what ended up, ultimately drawing me to specialise in palliative medicine.

Also, it made me realise I needed a lot more training than I had received through regular medical school or residency.  So, my patients – and I think most physicians would agree – have taught me the most about medicine.  What I’ve been excited about with the POST form is that it helps to take that experience and reach more people by improving the whole [indecipherable 03:02] that we provide to patients and empowering them for them to make the choices they feel that are best for them.

I found that patients, no matter where they are with their disease or their understanding, they have infinite amount of wisdom about what’s important to them.  If we can support them and listen to them, we can gain a lot, personally as a provider and as a healthcare system.  So, there has been a countless number or patients that I’ve seen improve, that I’ve [indecipherable 03:41] to be their caregiver at that time and improve the outcome from the standpoint of the level of peace, comfort.  Not just for the patient but for the family and the legacy that they leave behind.

Emily:    Yes.  There is something profound about death beyond just the spiritual aspect of it, for folks who feel that way about it.  But there is something beautiful about dying well and with dignity and with the wishes of the patient respected.  I can see what the draw would be to that.

Dr. Pile:    Yeah.  Again, death itself is not a disease.  It’s a life event.  We do die of disease but to treat that as a disease in itself is a problem.  So, if we can intervene early, and again every patient that I’ve encountered, one of their goals is always to extend life as long as it can be meaningful.  So, that’s always our goal and the real positive things I’ve seen over the last 20 years of palliative care is that we’re finally having outcomes data similar to outcomes data you have for other interventions, whether it be medicines, chemotherapy, surgeries, and the outcome benefits are astounding.

They improve patient satisfaction, they improve comfort and they extend life.  There’s countless studies now that show that good palliative care, providing, empowering patients, relieving their suffering, not only improves quality of life but quantity of life and it’s very reassuring to see.  We had noticed that anecdotally, in the hospice community for decades, but it was nice now that we have proof.

So, patients … again it’s not just either or [inaudible 05:39] or the people think ‘I’m either going to have this aggressive care and extend my life or I’m going to forgo that and shorten my life’.  In reality, you can get the best of both worlds; extend your life and receive good comfort measures.  That’s the most exciting.

Emily:    Yes.  I mean, the reason why people are living so much longer is because of some of these aggressive measures.  Is that correct?  That two or three decades before a person dies, at this point, they may receive some of those life-sustaining treatments after suffering from something like a cardiac arrest, and then go on to live a healthy, productive life.  And then their body will wear out in a different way and that’s more often the case now?

Dr. Pile:    Yeah.  Again, almost all diseases can become more diseases of [inaudible 06:35].  We can extend life.  What we’re looking at with the standpoint of when the focus switches to comfort and how it extends life, again at a point in the disease process, that it progresses to a certain point [indecipherable 06:57] interventions, that the burden of the interventions actually end up shortening life more than extending life.  Where is that point for every disease?  It’s very complicated to predict that point.  If you’re a cardiologist, an oncologist, pulmonologist, it’s hard to predict that point.

What I’ve found is the best person to predict that point is actually the patient.  No matter what their education level, they kind of know when … if they are informed and they don’t feel good and they’re not given false dichotomies and false choices of either or, they kind of know when it’s time to focus in a certain way.  Again, if they’re comfortable and they can [indecipherable 07:38] supported and have the information.  So, I found that patients are the best predictor of when the goal should change and that’s, again, it’s a very humbling experience as a physician.

As a physician, I think patients … my expectation is that I would tell my patients this is [indecipherable 07:55] what you need.  I’m learning more and more I have to listen to my patients.  I actually encourage them to speak up because they’re looking for me to direct them and it’s that combination of improving the communication between patients and families, and then as a palliative medicine physician, being that liaison with the whole healthcare system.  Because they might be seeing three or four different specialists at this point, and how do you navigate?

So, as you talked about in the past, we don’t have that family physician anymore, that one general practitioner who knows you.  Our system doesn’t lend itself to that anymore.  So, we have to try to create that now in a very short period of time, but it can be done.  Just like families and patients need to improve communications within their structure, then they could [indecipherable 08:44] decisions so the family is all on the same page.  We, as a healthcare system, have to improve communication in the same way so we can meet their needs.

Emily:    Do you ever have patients who turn to you and say, ‘what would you do if you were me?’

Dr. Pile:    Sure.  I think that can be a common request and since I’m not the patient I try to again reflect back on the patient and what I know of that patient, and try to put it in that context.  Because I don’t know that I could ever advise a patient based on my experiences alone.  They really need to use their experience and they do.  Patients have a rich experience, rich life experience.  They’ve made difficult decisions.  We can get very caught up on … that we made, that this is a life or death medical decision that’s very complicated.

But patients have made complicated decisions throughout their life; who they’ll marry, what job, where they’ll live.  They have the ability to do this.  They’ve done it.  So many patients are definitely more successful at that than I would hope to be about decisions that they’ve made in the past.  Again, it’s encouraging them and letting them realise that they have this foundation, and whether thatbe a reflection, it might be spiritually-based, it might be with their family.  They’ll go back to their foundation with this new medical information in the context, and come back and feel grounded and it’s a very important decision.

Emily:    Could this autonomy lead to, or has it led to in some small way, a home death movement like the home birth movement?

Dr. Pile:    Yeah.  I think if that’s what you’re looking at, I think there’s a lot of parallels.  Early on, in the ’50s, ’70s, the birth movement had become very medicalised, this life event.  Sure, there’s medical issues that come up.  It’s a medical, but it’s not truly a medical event.  So, there was a backlash and again it was led by the patients and women.  There wasn’t traditions coming in touch with their feminine side and realise, ‘hey we’re medicalising it’.  They listened to the patients, finally.

Mostly, I think, probably, you know, just from the standpoint of more of a catalyst.  Patients went where they’re going to be heard so there was that demand.  I think we’re seeing similar movement now.  The patients want the same caregivers that [indecipherable 11:37] not caregivers, they’re [indecipherable 11:41].  So, there’s certainly that movement.  The one drawback I think that keeps this from having that same parallel is that death is a sad event where a birth is a very happy event.

So, I think the underlying structure of the human condition to avoid death, because even if it goes well, it’s still sad, that that makes it a little bit more complicated.  But I think people are realising that without improving it, we’re making it sad, and worse than sad for patients to experience and the families that go through it.

Emily:    Has working in this field of palliative care since you’ve come to it changed you?

Dr. Pile:    Yeah, very much so.  Yeah.  I mean I think I was very geared to fixing things and disease eradication and being in control.  I mean, most physicians are and we don’t go into … there’s always a sense of control and mastery that leads people to be a physician.  You don’t get into medical school unless you get As in everything and do well on tests.  And then you take that very competitive subset of people and put them all together.

Again, I started to understand more of how to be a facilitator and how to listen to my patients as opposed to tell them, and to learn the reality that my patients, they’re not broken.  They don’t need to be fixed.  They need to be supported.  They need help.  That’s a different concept.  So, yeah, it’s been a very, again, humbling and maturing experience that my patients have blessed me with.

Emily:    Wow, what wonderful work.

Dr. Pile:    I appreciate the time, Emily.

Emily:    This is Emily with Health Professional Radio, talking to Dr. Christopher Pile from the Roanoke Good Samaritan Hospice.  Dr. Pile, thanks again for all of your time and everything that you shared with us today.

Dr. Pile:    Thank you Emily.

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