My essay on prescribing wine in palliative care on Medscape has attracted lots of comments, and that’s good: we need to put this issue on the table and make it part of our discussion about well-being as a goal of medicine, and as part of care near the end of life.
Food can be good medicine–the best medicine–and wine can be part of it. I’ve reproduced the essay below, with references, in case you can’t find it easily on medscape.
A common question I’m asked is…does grape juice have the same effect? Maybe a little, but we don’t know for sure. There are studies comparing red grape juice and red wine (and de-alcoholized red wine), but they are nearly all in vitro, in animals or on laboratory parameters–polyphenol bioavailability, platelet aggregation, antioxidant potential, atherosclerotic change.
I would love to see a head to head comparison of grape juice and red wine on relevant clinical outcomes–what people really care about: well being, energy, longevity.
Near the end of life, patients and families should have whatever they like. And I did find one glass-to-glass study: dealcoholized red wine lowered blood pressure more than red wine…or gin. ( American Heart Association ).
Prescribing Red Wine: An Rx for the End of Life
Prescribing wine might seem like anathema to some physicians, as heavy drinking (> 3 drinks per day) is a recognized cause of morbidity and mortality. But there is now good medical scientific evidence for regular modest red wine consumption as part of a healthy life. There is even more compelling evidence for prescribing wine to patients who are near the end of life. Here, I will focus on the latter.
There are thousands of studies of the risks and benefits of wine and its effect on health; nearly 200 recent ones are listed on the Boston University Scientific Forum site, with expert commentary. While some experts believe that the health benefits of red wine are related to the presence of alcohol, most of the evidence shows that the polyphenols in red wine confer additional cardiovascular and longevity benefits.
Modest daily consumption of red wine is an integral part of the Mediterranean diet, which is likely effective for secondary prevention after myocardial infarction. More here.
For primary prevention of cardiovascular disease. ( wiley.com ).
But this long-term large scale study finds that moderate wine intake, especially red wine, among people with well-controlled type 2 diabetes, and as part of healthy diet, lowers cardiometabolic risk and appears safe. ( annals.org )
Red wine becomes red only after crushed red grapes bathe for a day or two in their own juice. Anthocyanins leak out from the grape skins to color the pressed juice, which is otherwise nearly colorless. Grape and wine phenolics, including anthocyanins, resveratrol, tannins and other compounds are complicated, fascinating molecules ( WSU )The concentration of phenolics in a finished wine varies by grape type, and by how the wine is grown, made and cellared. Even white wine, with little grape skin exposure, may have health benefits. ( annals.org )
A glass of wine is five ounces (150 ml) of 12 percent alcohol wine, one fifth of a standard 750ml bottle. Lower alcohol levels–under 14%–characterize Mediterranean style wines. In some parts of the Mediterranean it is traditional to drink water along side wine. A sip of one and then the other serves both to dilute the alcohol level and to allow the glass of wine to last the length of the meal. Wine drunk slowly improves the enjoyment of the meal.
Wine by prescription means taking the right amount: not too much but not too little. For whom might an as-needed wine prescription be appropriate? One group: people who are near the end of life, who would like to have a glass.
The Clermont-Ferrand hospital in France offers a wine bar to palliative care patients and families “to help them relax and speak freely…in an attempt to restore long, taste, desire and even pleasure.” ( NY Daily News )
The palliative care center director who proposed the bar, Dr. Virginie Guastella, is quoted as saying “It’s a way of rethinking the care of others, taking into account their feelings and emotions that make them a human being.” ( Escoffier ) The wine is reportedly donated and is served according to an institutional protocol. A wine-benefits training program helps staff identify ways in which wine enhances well-being.
Well-being is an underestimated goal of medicine: some, like Atul Gawande, argue that it is the primary goal. The notion of “healthy life expectancy”, i.e., life expectancy in a healthy state, is a measure of population health: in the U.S., it is lower than average life expectancy by between seven and 19 years. ( CDC )
‘Medically supervised’ wine tasting with patients near the end of life is currently illicit in most health care institutions. A review of the JCAHO, AHA, CMS and NHPCO websites finds no mention of it. Physicians can prescribe alcohol as a competitive inhibitor for methanol poisoning and ethylene glycol poisoning. Alcohol has previously been prescribed for the treatment of delirium tremens, and during Prohibition, for “medicinal reasons”.
Reports of physicians who have provided access to wine, beer and spirits to patients near the end of life show that such care is viewed as heroic and caring.
Small things make a big difference in life when little life time remains, and sensual pleasures are among the most rich. Although alcohol right before bed promotes sleepiness, it interferes with sleep later in the night: people who want to sleep soundly should stop drinking at least two hours before bed.
People near the end of life should eat and drink what they like, and be free of others’ fears of potential harm to themselves. As the dying often lose interest in food, it seems especially cruel to withhold wine from any person near the end of life who may want it.
Inpatient centers and home hospice programs are good candidates for prescribed-wine-as-desired programs, which may be considered part of comfort care, and indeed, comfort food. Such programs and prescriptions honor the humanity which medicine strives to offer, at its most compassionate.
So a model prescription might be:
Rx: Red wine of choice
- Drink one five ounce glass slowly, at night, no less than two hours before bed, preferably with food and at meal time, and with at least 10 ounces of water, most nights prn.
- Do not exceed or combine with other alcoholic beverages. May repeat x1.
Physicians should suggest that patients drink the wine they like, no matter what its score, pedigree or terroir. If they’re unsure what they like, they might try a scratch and sniff wine book, or buy local wines first. The pure pleasure of smelling and tasting liquid magic with your meals is hard to beat. Doctor’s orders.