Listening is doctor’s key to dignified end-of-life care

Paul Kleyman | 4/10/2013, 7:10 a.m.

PALO ALTO, Calif. — How does a doctor specializing in saving lives turn into one of the nation’s leading experts — and medical educators — on end-of-life care?

Dr. Vyjeyanthi “V.J.” Periyakoil says her 25-year journey from medical school in her native India to directing Stanford University’s palliative-care fellowship program taught her that the art of healing lies in listening to her patients. What she heard wasn’t always in the medical textbooks.

What they told her led Periyakoil to becoming a leading voice in the movement to re-conceptualize end-of-life care from limited hospice treatment in the last six months of life to comprehensive treatment for profoundly ill people.

“Much of my work had been on the importance of dignity in health care,” Periyakoil recalls.

She found that patients “cared more about concrete things — ‘Treat my pain first, take care of me first — then you can treat me with respect.’ For patients, that meant good pain care and symptom management, which is good palliative care.”

Periyakoil began her practice in the United States as a resident in the crowded wards of Stockton’s San Joaquin General Hospital. Her patients were mainly “migrant farm workers, people with no insurance, people who didn’t want to give you too much information” because of their immigration status or their fear they couldn’t afford the treatment being prescribed.

She said she felt especially awkward when the medical advice she offered proved irrelevant to her patients’ lives. “There was a mother of young children who had two jobs. I would tell her, ‘Why don’t you put your feet up? Why don’t you eat more protein?’ She’d try to answer, ‘Well, I have to get back to work,’ and I’d just continue to give the same silly advice.”

Sensing her frustration, it was the patients who tried to reassure her. “Oh, yes, I’ll do that, doctor...Don’t worry about me,’ they’d say.”

Struck by how many of her Stockton patients were immigrants, like herself, Periyakoil worked hard to make herself understood while also sensitizing herself to cross-cultural issues.

“When I first came to the U.S., I could read and write English very well, but because of my accent, my patients couldn’t understand what I was saying,” she recalls.

She focused on enunciating every English word clearly, and came to appreciate nonverbal forms of expression — like a worried look that exposed a patient’s unspoken concern. The better she was able to communicate, the more likely her patients were to follow her medical recommendations.

Later at Stanford Medical School, where Periyakoil studied geriatric medicine, she discovered another gap in her knowledge from patients who were deemed to have only six months or less left to live. Admitted to hospice care, their cure-oriented medical treatment would often be stopped in favor of “comfort” care.

“I had a hard time giving up on these patients,” she admits.

Her determination to improve the quality of their lives, no matter how much time they had left, led her to realize that palliative treatment should begin as soon as a patient is diagnosed with a life-threatening disease. Care provided only when someone becomes eligible for terminal hospice coverage comes too late to fully help them.