Tag Archives: Geriatrics

Becoming The Standard of Supportive Care

August 2, 2017

 Meet William Dale, M.D., Ph.D., the New Arthur M. Coppola Family Chair in Supportive Care Medicine
William Dale, M.D., Ph.D., recently joined City of Hope from the University of Chicago, where he was an associate professor of medicine and section chief of Geriatrics and Palliative Medicine. He completed his medical and graduate school education at the University of Chicago, and his residency in internal medicine and geriatrics fellowship at the University of Pittsburgh. He is a board-certified geriatrician and palliative medicine physician with a doctorate in health policy.

Q: What brought you to City of Hope?

I knew of City of Hope primarily through my association with long-time colleague (Vice Provost) Dr. Arti Hurria. We both have keen interests in geriatric oncology. I also knew of the well-respected Department of Supportive Care Medicine here, which is a rather unique model that doesn’t exist elsewhere. Here, the department brings together so many aspects of comprehensive cancer care under one umbrella: palliative care, social work, psychology, psychiatry, patient education, patient navigation, volunteer services, and the Positive Image CenterSM – 13 divisions in all. It is very rare to have so many disciplines working closely together under one roof. Most places have to pull together multiple providers from several different places, but it makes perfect sense to keep the patient at the center of your care and to know they have a team around them. We do that.

Q: Many think that “supportive care” and “palliative care” are interchangeable terms. Are they?

Palliative care is a holistic specialty that focuses on maintaining a patient’s quality of life and managing their symptoms. Its focus is on maintaining a high quality of life throughout the cancer care journey, including when therapies aren’t available to control the cancer and the patient is nearing the end of life. Hospice care – caring for patients in the last six months of life – is often confused with palliative care. While hospice care is part of excellent palliative care, they are not the same. Supportive care is a broad-based patient care approach, while palliative care is a medical specialty that focuses on preserving quality of life.  Our department is inclusive.

Q: Tell me about your role as chair. What would you like to accomplish?

I envision supportive care at City of Hope being the top program in the world. We already have a unique world-class clinical program. What we haven’t had enough of is scholarship in supportive care, which we are building. I want to bring researchers here, which we’ve already started by recruiting a senior-level director of research we’ll be announcing soon. Also, we’ll have a new concentration on geriatric medicine – the care of older adults. Finally, I have a great interest in models of cancer care. Creating programs for optimally caring for vulnerable patients on a financial foundation of personalized care, integrating oncology and supportive care that is sustainable.

I want City of Hope to be THE place, the standard for supportive care programs.

I want City of Hope to be THE place, the standard for supportive care programs.

Q: How did you come to choose a specialty in geriatric palliative medicine?

I’ve always liked older people! I remember caring for them when I was in an intern in internal medicine – when my colleagues avoided the complex older patients with multiple problems, I liked the challenge these patients presented. In my VA clinic in Pittsburgh, I loved hearing fascinating stories from the old World War II vets. Older people can have quite a few health problems already: They may have several diseases – hypertension, cardiovascular issues, diabetes – and then you add cancer on top of that – it’s a lot to deal with. There are unique challenges and considerations when taking care of this age group.

Q: How do you expect to be involved in research in your new role?

I have always been interested in medical decision making and health services research, which we will build at here. Much of the data we currently have from cancer treatment trials comes from a younger, healthier set of patients. While there are a few older patients enrolled, they are largely healthier patients who don’t represent the majority with cancer. So we often don’t know how a less fit older patient will respond to most therapies – we just have to guess, often causing lots of side effects. We need research that will allow us to make more informed decisions for our older patients, based on better data, and to using interventions and a system of care tailored for them. If we can target interventions that get results that truly improve their functioning and quality of life, then they aren’t in the hospital as often. The older, sicker patients are the ones who currently use the most resources, and tend to be the most expensive – for them, us and society. How can we better care for them? Often, supportive care interventions are the answer.

Q: Is there research you are leading now related to this?

Arti (Hurria) and I are continuing to collaborate on several studies, including a recently submitted National Institutes of Health grant that would build a nationwide research infrastructure for older patients, which also includes my City of Hope colleagues in supportive care (Executive Director Matthew Loscalzo, L.C.S.W., the Lilliane Elkins Endowed Professor in Supportive Care Programs), nursing (Nursing Research Director Betty Ferrell, Ph.D., R.N.), and aging science (Population Sciences Professor Mark LaBarge, Ph.D.). We want to get better, more representative data for these patients who have the highest burden of cancer and other diseases, as well as mentor young researchers to enter the field. Along with the new Center for Cancer and Aging here, which Arti, Mark and I lead, we want City of Hope to be the national leader in this type of research. They can come to City of Hope, and we would have some national level resources we can give them access to.

Q: Did you always want to be a doctor?

As a kid growing up in rural Illinois, with animals always around both inside and outside the house, I wanted to be a veterinarian. But, I’m ultimately a people person, and I wanted to make a difference in people’s lives, so I became a doctor. I’m also a bit of a policy wonk about health care, so I earned a Ph.D. in health policy. Melding my clinical love of older adults with my research love for medical decision making and health services, I look forward to building a department that brings this together.

Q: How are you liking LA so far?

Although I’ve spent my entire adult life in the Midwest, almost entirely in Illinois, I am loving Southern California! My very first job as a 16-year-old in Illinois was as a lifeguard. I loved being at the pool all summer, and spent seven years doing that. During that time, my favorite bands were The Beach Boys and The Eagles, and I fantasized about living in LA!  When this job came open at City of Hope, it was a dream come true from my youth.

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Filed under City of Hope, Decision Making, Geriatric Oncology, Geriatrics, Health Policy, Palliative Care

John Adams on Aging, Illness and Death: A Geriatrician’s Unusual Book Review

“My House is a Region of Sorrow, Inhabited by a sorrowful Widower…The bitterness of death is past. The grim spider so terrible to human nature has no sting left for me.”

–John Adams to his son, John Quincy, upon the death of his beloved wife, Abigail.

A Geriatrician’s Perspective

In First Family, Pulitzer-winning historian Joseph Ellis elucidates the character of our least-venerated, least-appreciated Founding Father, John Adams.  He brings Adams to life by presenting his life appropriately intertwined with one of our most-beloved First Ladies in history, Abigail (Smith) Adams.  As with all Ellis’s books, it is written with clarity, verve, and eloquence, mixing the Adams’ remarkable public career with his no-less remarkable marriage and personal life. How many people can claim that they effectively chose a country’s founding document (Jefferson), Military Commander (Washington), and Chief Justice (Marshall) and to have fathered a future President (John Quincy)?  And these are merely sidelights to a remarkable life of achievement. Rather than discuss the usual political topics, I focus here on a favorite topic of mine: aging.  Among the gems of insight scattered throughout this book are Adams’ (and Jefferson’s) thoughts on getting older, failing health, and death.  For a man who lived past the age of 90, at a time when life expectancy was closer to 40, his thoughts sound remarkably modern, hinting at the universality of these issues.

Adams and Jefferson on Aging

In the twilight of their lives, John Adams and Thomas Jefferson famously corresponded, reflecting on their lives and debating their political differences.  The correspondence had ended when Jefferson and Abigail Adams — John’s lifelong partner in all things domestic and political – exchanged letters, unbeknownst to John.  Jefferson denied paying a known “journalist” scoundrel, James Callendar, to libel John – which was a lie.  Abigail directly called Jefferson out on this lie, writing that, after their many years of friendship, “the Heart is long, very long in receiving the conviction that is forced upon it by Reason.”  After noting that Jefferson’s critics had accused him of being a disingenuous and dishonorable, steely-eyed Abigail says, “Pardon me, Sir…I fear you are.” Nobody he admired had ever been so direct with Jefferson on this point.  The result was that no further correspondence between households occurred for nearly a decade. Wouldn’t we all love to have such eloquent, steadfast support from our partner! After many years of bitter silence over such issues, Adams reignited a conversation, writing to Jefferson that, “You and I ought not to die before We have explained ourselves to each other.”  The resulting correspondence between the two, 158 letters worth in total, memorably did just this, as each posed for posterity, knowing their letters would be read by History.  While most discussions of this correspondence focus on the political ideas between the two, such abstract thoughts were interwoven with other topics.  This included sublime thoughts on aging, health, and death. In one exchange, Jefferson offers (p. 238): “But our machines have now been running for 70 or 80 years, and we must expect that, worn as they are, here a pivot, there a wheel, now a pinion, next a spring, will be giving way. And however we may tinker them up for a while, all will at last surcease motion.”  In my clinic, helping my older patients navigate through issues of their “machines” running down, dealing with multimorbidity, frailty and polypharmacy, I often feel just like some mechanic, “tinkering” with their delicate “parts”, hoping to keep them moving as long as possible.  Many patients of mine, especially the men and the engineers, complain about their declining abilities like cars springing leaks, rusting through, and falling apart. In response, Adams worries about something slightly different: “I am sometimes afraid that my ‘Machine’ will not ’surcease motion’ soon enough; for I dread nothing so much as ‘dying at the top,’ and thereby becoming a weeping helpless object of compassion for years.”  Adams’ had an ongoing fear of losing his mental faculties. As Ellis notes, Adams had seen the mental deterioration of his cousin, Sam Adams, and John “feared dementia more than death.”  This is the sentiment I so often hear from my patients, that their greatest fear is getting Alzheimer’s disease. My own experience with patients confirms this as one of their greatest fears as they grow old.

Literary Illness

Among the literary gems unearthed by Ellis are Adams’ colorful descriptions of his various ailments.  He creates a lovely neologism to explain one particular problem:  the “quiverations” in his hands.  These tremors prevented this inveterate, lifelong writer from doing so effectively.  He had to resort to dictating his ideas to whatever grandchild he could convince to listen.  I love this term, which captures the spirit of how tremulousness must feel from within. I’ve had patients say how they simultaneously don’t notice their tremors, but how annoying it is when they have to deal with it.  I’m likely to adopt this term for my patients, as I love the verve it imparts to the condition. In another case, he complains that his “constitution is a glass bubble or a hollow icicle”.  He worries that, “A slight irregularity or one intemperate dinner might finish the catastrophe of the play.”  He was on the brink, in which a new stressor might push him over the top.  I can think of no more poetic expression of Fried’s Frailty, which is a physiological vulnerability to stressors which predisposes older adults to morbidity and mortality.  Thinking of my frail patients as “glass bubbles” is a perfect metaphor for those struggling through another Polar Vortex in Chicago.

Death, Dying, and the Spirituality

When Abigail died, as the quote above indicated, Adams was grief-stricken for nearly a year.  After 54 years of marriage, he was lost without his lifelong confidant.  Grief at the death of a spouse or other loved one is a constant risk for older adults, especially if it leads to on-going depression.  It is a wonderful reminder of the blow such events can deal to our older patients. Adams despite a having a Deacon for a father (whom he deeply admired), had skeptical views of religion and the afterlife. In his later years, when asked about the Christian view on life after death, he jokingly responded that he assumed God would allow him to further debate Benjamin Franklin as part of the experience. Nevertheless, he did assume there was some sort of afterlife: “If it should be revealed…that there is no future state, my advice to every man, woman, and child would be…to take opium.” On the day of the 50th Anniversary of the Declaration of Independence, which Jefferson was chosen to author by Adams, the two Founders died within hours or each other, on July 4th, 1826.  Adams famous last words, “Thomas Jefferson survives,” were incorrect; Jefferson had passed shortly before his colleague.  Like two intertwined spouses, the two friends left their earthly lives together.

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Filed under End of Life Care, Geriatrics, History, Palliative Care, Uncategorized