Wednesday, September 16, 2009
“Moribund Obesity”: Palliative care diagnosis or poorly chosen label?
I’ve always had a fascination with how certain phrases influence practice and how established terms frame and reinforce provider attitudes toward the individuals they care for. I recently began exploring the experience of nursing home life among obese residents, and in a literature search came across Deepak Gupta’s letter the editor “Moribund Obesity as a Palliative Care Diagnosis.” Now, add to my list of questionable palliative care related diagnoses (presently including: psychogenic mortality, failure to thrive, organic brain disease, et al.) the newly coined “moribund obesity.” At the risk of oversimplifying, a morbidly obese individual achieves moribund status when usual interventions to reduce or control obesity fail as a result of some insurmountable barrier or collection of barriers—physical, psychological, social or spiritual. Most distressing in the article, suggested spiritual barriers include “inadequate self-control and the spiritual pain that comes from feeling worthless or abandoned by God.” I don’t know why, but I bristled when I read this. Perhaps it’s my reading a “blame the victim” subtext into this, or perhaps it’s that this seems to downplay the complexity of overeating, and emerging science suggesting neuro-physiological processes that may parallel addiction.
The adjective “moribund” runs the risk of becoming a “line in the sand”, defining when palliative care becomes appropriate. In the most extreme scenario the “moribund obese” label becomes the green-light for palliative intervention and discontinuation of other therapies. In addition, we risk overlooking the need for palliative intervention periodically or continuously across the course of a refractory chronic condition. In the case of obesity, this may be long before the morbidly obese individual satisfies criteria to earn the “moribund obese” label.
In all fairness, the tenor of Gupta’s commentary suggests a call to recognize the complexity of chronic refractory obesity and the need for palliative intervention. The reality is that most of our knowledge about the palliative care needs in morbidly obese individuals is based on anecdote. There are few studies that have documented the range of their palliative care needs or provided direction for comprehensive intervention. Complex, long standing, multifactorial conditions with poorly understood etiologies are often the most challenging to manage. They are often characterized by good days and bad days, by periods of remission and exacerbation—some explained, some not. We often attempt to capture these conditions using imprecise terms (e.g. failure to thrive) which may satisfy the need to diagnose but often result in suspending additional assessments vital to an effective palliative care plan. I am not sure that inventing a new term (moribund obesity) that attempts to capture when someone has crossed an ill defined line on the way to mortality is helpful. In the end such classification may have the undesired effect of relegating a sub-population of complex, chronically obese individuals to a palliative “island of misfit toys.” Perhaps a better tack is to banish “moribund obesity” to the “island of misfit terms.”