Palliative care occupies a unique position in the medical-ecology: it is a speciality that exists both in and out of the hospital and one that engages with but also rejects medical technology and treatment. As a result, David is situated both in the epicentre and on the periphery of the professional medical realm, allowing him powers of observation he may not have otherwise gained. Consequently, David said that his view of the hospital has changed as he has gained more experience: "When I started my medical training, I saw it as a place of treatment, care, investigations, it's where the sick went and were tested and treated and people came to see specialists. It was what separated it from GPs. And then, once you were in, you received everything that was necessary". In this sense, David used to view the hospital as a place where you had to surpass a certain threshold to enter - you had to be a certain level of sick, the hospital meant real trouble but also intense care. While this isn't necessarily no longer the case, it is true that we see more patients with non-urgent or non-critical issues attending the hospital for things that should be dealt with by a GP. Importantly, at the moment, we are also seeing patients staying longer in hospitals once they are admitted, as they receive more and more treatment - perhaps with little efficacy.
For David, this is what caused him to come to view hospitals "not just as that amazing place of treatment and specialist support but also of deceit“. Through his observation, David stated that on other wards in the hospital, he will see more and more patients who are at the end of their journey, with their disease having progressed so much that they are spending more time in hospital that out. As a palliative care physician however, David said that he is "privileged in the fact that a majority of [his] patients know they have a terminal prognosis and by the time they are referred to [him], know that that is the case." However, that he is also acutely aware that there are a large majority of patients in the community and in hospital who are at the end of their life, but this isn’t recognized by the medical profession, saying that as a medical profession, "we don’t give these patients the justice they deserve“.
With all the advances in modern medicine David said that nowadays, healthcare professionals are able to manage people's conditions much better and for much longer. However, whilst this might lead to longer life expectancies, concomitantly, this also causes the medical profession to lose the skill of being able to recognize when a patient is no longer getting any benefit from the treatment: “We are forgetting to actively look for that point and that means we are doing them a disservice. A lot of patients will have chronic conditions and are not given enough notice about how far they are along with their disease. I believe that this robs them of that time when they can get their affairs in order and plan for what they want. I feel that these people have been let down by the system“. In this sense, for David, it is about asking questions about at what point biotechnology is doing more harm than good, at what point death might actually be the better option and whether more harm is being caused by keeping a patient alive through biotechnology.
This in particular alludes to the even bigger questions and debates regarding the role of biotechnology in healthcare and the 'gaze' of healthcare professionals. Nowadays, biotechnology means hope - for a cure, a longer life, for health, for the eradication of illness. However, for David, hope as a result of biotechnology can actually cause more harm, as both medical professionals and patients lose the ability to see when enough is enough: “With all the treatments and technology we have, patients might think 'maybe this time when I go into hospital it will be the one that makes me better' and likewise, healthcare professionals are often always searching for the next best and newest treatment or clinical trial for their patient. Everyone has so much hope, which can be so dangerous." For David, however, it is about having honest and frank conversations with patients: "It is about saying that actually maybe this is the last year of your life but we can help you to live your life to the fullest. With a lot of patients that come to me, I would like to think that at some point in the last 12 months, someone could have intervened and had what would have been a really difficult conversation with that patient, but they would have had the time to plan. There is definitely an element of deceit and we aren’t just deceiving the patients, but we are also deceiving ourselves sadly."
In an increasingly technocratically lead health system, and where biotechnology is synonymous with efficiency, longer life expectancies, and better prognosis and treatment, it is easy to forget the psychological and social implications of their prolonged uses. Whilst being able to manage diseases and elongate life expectancies is indeed fantastic, the question of whether such exhaustive forms of management is beneficial in the case of terminal patients, needs to be considered. For David, due to the increasing use and evolution of technology, the distinction between curing and managing is being blurred.
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