My Medscape essay on Prescribing Red Wine in Palliative Care, which I’ve reproduced for you below, has attracted good stories and comments, and it is something I have thought a lot about, while also trying to decide whether to get labs on my 18 month old barrels of pinot noir and merlot now, or wait until we bottle, probably in June of this year, in honor of Sideways (worth finding on DVD).
Curiously, I have no such hesitancy in medicine: I know when to get labs and when to wait: winemaking takes the same type of careful observation as medicine does, but Malcolm Gladwell’s 10,000 hour maxim applies only to medicine, cooking and gardening for me, not to winemaking.
One omission from the Medscape column was this helpful book link: 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 the Essential Scratch and Sniff Wine Book, or buy inexpensive local wines first (wine that speaks of its place is work finding).
The essay is below, with links to references: enjoy!
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 , and for primary prevention of cardiovascular disease.
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. 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.
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.” http://www.nydailynews.com/news/world/wine-new-prescription-terminally-sick-french-patients-article-1.1888496). 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.” 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.
‘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.
The pure pleasure of smelling and tasting liquid magic with your meals is hard to beat. Doctor’s orders.