A Conversation with Dr. Steve Warren

Q: A lot of people don't know what, what hospice is. How would you describe it to me?

Dr. Warren: Hospice basically is a program that treats some patients in their last six months of life, that is, if the disease progresses the way that it's going to progress, that there's a possibility they would die. We try to treat them plaintively; we're going to treat their symptoms, treat their pain, treat the family members and the situations they are dealing with. It's a comprehensive program where we involve medicines, medical staff visits, dietary support, social workers, Chaplains and volunteers that go out and help patients and families try to get through these stages of dying. And so hospice basically is a comprehensive program to try to help families through this dying process and trying to help them go through it smoothly and without pain and trying to keep them without a lot of symptoms. Hospice has evolved in the United States over the years to where the federal government picked it up as a Medicare program

I think also that emotional part is the key thing that hospice is there for - to support both the patient emotionally and their family members. It's really important to help them through this dying process and their feelings and try to make closure on life. The emotional pain that people have sometimes it makes it really hard for family members to die. It's frightening to go through this death process because none of us have gone through it before and family members are really scared about it. I think that you can face death better if you understand what's going on a little bit better and I think that hospice tries to provide that basis for them. So I think hospice really tries to focus on that whole emotional part, the spiritual part, the emotional part, the physical part and bring them together and treat all of them and just not just treat one aspect of it.

Q: There's a really great need for pain management and pain control. How good a job do we do, especially in Utah, in terms of pain management for dying people?

Dr. Warren:I think in a lot of states there has been a problem that pain control hasn't had a lot of support behind it. People always thought that somebody would be addicted to medications and that people have been associating pain medication with the problems we've had with addicts. As a result, a lot of people have died with pain. Sometimes pain medications are needed for both physical pain and suffering pain, and I think that our nation right now is sort of coming around to that point of view. The National Institute of Health finally opened up the first Pain and Palliative Care Program to try to focus more on pain. Instead of just checking their blood pressure, pulse, respirations and temperature, we're now looking at pain as a real vital sign that we need to treat. The government now has given us mandates on pain treatments it because we're violating patient's rights if we're not treating their pains and taking them seriously and giving them the right amount of pain medication to keep them comfortable.

A recent study took 10,000 patients that were treated for chronic pain and they had zero patients that became addicted out of that. Another study with 14,000 had 3 addicted out of the 14,000 that were on high dose pain medications for chronic pain. We don't make addicts; we're trying to treat the pain and we're trying to keep them comfortable. Sometimes just holding the patient's hands will treat some of the pain, but often times we do need pain medication to treat them, and we try to give them the right amount. We don't want to sedate them so they can't talk or be with their family members, but we want to treat them if they have enough pain medication and not make them feel like they're a criminal for asking for pain medication. But pain medication is there to treat their pain and to help them through this dying process.

Q: What's your role as a hospice care physician? What do you do during this whole scenario?

Dr. Warren: When people are certified on the hospice program, their attending physician or the physician has been taking care of them for years is still in charge of their care. My role is sort of as consultant. If they have some pain issues, I can find some answers or help them with some of those issues. My other big role is to supervise the review of all the patients each week to make sure we're caring for all their issues. We have the whole team together, the dietitian, the social workers, the Chaplains, the nurses and we talk about each patient to make sure we're doing a comprehensive plan for them. I also try to educate people; the public through public talks, the medical staffs through grand rounds and their offices, and the hospice nurses through frequent in-service lectures to keep their skills up. So I do a lot of education, I act in a consulting role to physicians, and then I do have my own patients that I visit and try to take care of.

Q: Dr. Warren, I'd like to talk a little bit about your Monticello experience. Explain to me just how you were a real doctor and talk about the rural attitudes toward death and dying.

Dr. Warren: When I finished my residency program, I was on a national service corps program and ended up down in Monticello, Utah...rural America. I learned a lot about life and death down there with those patients who see it in a different perspective. They don't have the fancy machines, C.T. scanners, ICUs. in the hospital. I think people have a totally different attitude; they know that death does occur, that everyone is going to go through that life cycle. They see it with their animals, they see it with people around them and they just expect it. And so they don't expect a lot, they only want to be treated like a human being, to be out of pain and to have people around them that love and care about them. Down there I did a lot of holding hands in somebody's house or in the hospital and hearing them say "No, I don't want anything done. Just keep me out of pain. Keep me comfortable." And they pass away as you're holding their hand. Coming out of a Washington D.C. medical school with a big university hospital where everything was done for everybody to have a patient live longer, and going to a small town where there is an attitude of everybody has to die, let's do it in a real graceful way and a pleasant way, that influenced me tremendously when I moved back up into the Salt Lake / Ogden area. I started getting a little bit more involved with the hospice program and realized that was the same type of experience that I was having down in Monticello, that people had that attitude of "I'd like a good death. I want to be home with my loved ones and that death is a natural progression of things but let's do it the right way and try to help people through it."

Q: Had you seen a lot of people dying in ICUs? Do you see a real difference in urban attitudes?

Dr. Warren: I think you do. That technology is improving is one of the things in our society that stays in people's minds. People have got used to so much technology and so much that can be done, that they expect that. In a rural area, where they haven't had technology available, they realize that people can die in a peaceful manner and that's what they expect. In the urban areas, you see more of the "let's do everything" type of attitude. I worked in a big major university hospital in Washington, D.C. and then my residency program in an ICU. I saw a lot of deaths in the ICU and no family members were around because they were in the waiting room while we were all around the patient trying to do stuff on them and they died that way. We'd have to go out to the waiting room and say "Your father or your mother passed away and we did everything we could." When I was in Monticello, all their family members were around the patients knew when they were dying. They were there around them with their spirit and the love that was there. So I really have seen a big difference between the two experiences.
You've got a personal story with hospice. Your mom on it. Was that an easy decision to put her on?

Dr. Warren: I think that, in some ways, it's hard to make that decision to say your Mom's going to die and to realize that it's going to occur. But in some ways it's an easy decision. It was realizing that my father is getting older and it's hard for him to take care of my mother. I think it was almost a relief to say she's going to die but now I can get somebody into help my father and give him that emotional support that sometimes is hard to give to your father. It's nice to share those feelings with somebody who's a professional, a social worker or a bereavement counselor that can work with him. And knowing that your mom's being taken care of by aids that are watching out for her and giving her that tender loving care and support. To me it's a double edged sword; you hate seeing someone pass away that's close to you, but on the other hand, I knew that the hospice program was giving so much support that would really help my father and my other siblings and give that support to my mom. I think she needed that, it's given her a lot more than just if she died without any support.

Putting my mom and dad on the hospice program has probably been the best thing that I've seen because it's taken a lot of pressure off of my dad and it's helped my mom with some more tender loving care and some physical care that she needed. And it's helped me as a son just knowing that my mom and dad are taken care and that there's someone there watching out for them.

Q: Is there a dichotomy between you as the doctor and you as the son? How's that struggle going for you?

Dr. Warren: Through this process of making this documentary, I have had to bring out more of the son part in me. As physicians we're very good at hiding our emotions and stuffing them down and I think going through the process of talking more about it and getting my feelings out, it's come to the focus more as a son than as a physician. I've had to deal with that and I think that I could've have easily just kept the physician role, and probably when my mom died I would have experienced the emotional part to it. But I think through this process that we've gone through right now of talking about it more and even having more conversations with my dad has opened my eyes as a son and not as a physician. I realized that I have hidden behind that physician role often times and it's easier talking about physical symptoms than talk about the pain of losing somebody and losing your mother because you can always just put them in the third person as a physician. But I think as a son, yeah, I think about it more then I have before. It's still hard because I don't think I can interact as well as my mother as I'd like to because of this disease process, but at least I feel like my emotions are more there and trying to keep in tune with them and what's going on in her, within my life as she's passing away. We're taught well in medical school to stuff, stuff, stuff your emotions. We do a very good job of doing that; I think it's harmful to us physically and so I think this has been a good process for me to go through.

Back to Dr. Steve Warren's biography