Technology Transfer and Continuity of Care by a “Consultant”

Even though I was taught in medical school more than 40 years ago that nothing could be done for emphysema and advanced chronic obstructive pulmonary disease, I never accepted that dogma. My beliefs were confirmed when we began to observe the tremendous clinical and physiologic benefits of long-term oxygen therapy delivered by a newly available liquid portable system. Soon, oxygen therapy became integrated into a program of pulmonary rehabilitation. Pulmonary rehabilitation was slow to take hold and was usually carried out in a program supervised by pulmonologists. As controlled clinical trials proved the value of long-term oxygen therapy in increasing the length and enhancing the quality of life, many patients in the United States and around the world benefited from it. Later, primary care physicians began to recognize the value of pulmonary rehabilitation and the role of oxygen. By the mid 1990s, it was estimated that more than 800 000 Americans received long-term oxygen therapy.

Of course, all patients whose conditions have improved with oxygen and pulmonary rehabilitation still must face inevitable death. Thus, as my patients aged and died, I also became interested in ethical issues in terminal care. Keeping people comfortable at home became a high priority. To accomplish this, I frequently made house calls, and still do.

Bill was 86 years old when he was referred to me by his primary care physician for progressive dyspnea on exertion due to emphysema. Although Bill had been a heavy smoker in the past, he had quit 12 years before, at the time of a bowel resection for colon cancer; disease had not recurred. Bill loved the outdoors. He played golf twice a week, and occasionally went trout fishing. This was quite an accomplishment: On my initial evaluation, his FEV₁ was only about half of the predicted value, with …