Overcoming the Inevitable in Medicine: Doctors Simply Doing Their Best Under the Circumstances
There is the story of the two campers whose tent is about to be invaded by a hungry bear. Despite both knowing that a bear can outrun a human, when one camper noted that the other was putting on his running shoes and tightening the shoe laces, the camper asked the other "why are you doing that?" The other camper responded "I don't have to outrun the bear, I just have to outrun you!"
I think there are a lot of times in medicine when doctors are faced with the task of simply doing their best under the circumstances. It is not that they are necessarily wholly incompetent, it is just that diseases, not the doctors, can have a way of controlling the outcome of the illness. Physicians faced with such diseases in their patients such as cancers and other illnesses may rarely want to give up. They may decide to continue specific treatments to rid the disease, denying the obvious that the disease is overtaking the treatment. Sometimes the patient or families encourage the physician in this regard. This is not at all an uncommon scenario presented to hospital ethics committees for consultation.
There should be a time, however, when the doctor realizes and accepts the inevitable and begins approaches which are the best treatment and benefit for the patient under the circumstances. This may involve energetic palliative care, care to relieve suffering but treatment that no longer attempts to cure. One cannot always think that doctors can outrun the inevitable but, like the camper, must find alternate ways to accomplish the best under the circumstances. Any objection from my visitors? ..Maurice.
Graphic: Hungry Bear from KRQE.com via Google Images.
posted by Maurice Bernstein, M.D. @ 3:16:00 PM
15 comments
15 Comments:
I have seen such denial from a physician. The patient shouldn't have to figure out, and ask for, hospice / palliative care.
Of course, physicians are human too, and may view such admissions as a failure - they and their skills have been defeated by the disase.
Nonetheless, physicians should strive to do the best for the patient, and offer such care when appropriate.
Of course, when there is even a sliver of hope, I believe it should be the choice of the patient. The physician should give his/her opinion, that future attempts at a cure are futile, and offer paliative care. Not force that upon the patient, of course.
TAM
TAM. sometimes that "sliver of hope" of the patient, the family and even some doctors persists and never grows into a "slice" or more. Meanwhile, the patient maintains life but suffers and one complication over another piles up, yet the "sliver" persists to those who hold that hope. The ethical issue, among others which then appears is one of distributive justice. Is it fair to other patients, in circumstances of limited treatment resources, to be turned away from facilities or immediate opportunities to utilize those resources because another patient has continued use of those facilities or resources to maintain that "sliver"? This issue of distributive justice is a hushed up consideration in most ethical decision making discussions but is always there as the "elephant in the room". The consideration of therapeutic triage is often not made until the resource has been dramatically reduced, such as the huge depletion of the availability for others of a specific blood type utilized by a single patient or in the case of an influenza pandemic the gross limitation of ventilators and therapists to monitor them.
"First come, first served.. and continued to be served" is not always the most ethical way for medicine to be practiced. And at some point the "sliver of hope" must be transformed into more than a sliver of terminal comfort care. ..Maurice.
Aside from the issue of distributive justice, there is another ethical consideration. Obviously, and for now, the choice to maintain that 'sliver' of hope rests ultimately with the patient.
I work with physicians who engender hope in their patients to such a degree as to redefine 'the sliver'; it becomes, in essence, more of a 'slice'. Often, even when the futility of further treatment of the disease is obvious to caregivers, and even untrained onlookers.
For the sake of the patients and caregivers, whose lot continues, regardless of distributive justice - or in spite of that - how do we convince doctors to do their ultimate "best"?
I don't know Maurice, that is a hard one. I personally would never want to be on an ethics committee!
It's so hard - sometimes people not expected to live surprise everyone, and do survive. So who is to decide? You're 99.9% likely to die - no more resourcese for you. What about 99%? Or... 95% (we're getting short on blood).
Where to draw the line seems like an impossible decision to me - I would not want to be the one to make it.
I personally though, could make the decision for myself - if recovery isn't very likely, I'd want to be told that, and imagine that I would choose to be comfortable.
TAM
TAM,
Thank you for connecting the 'dots' of my concern to that of distributive justice.
Defining a doctors' "best" is an even less well-defined term within the context of medical ethics. (I suspect I was venting a bit because this issue frustrates me so much in my practice.) It is not in my power to know whether doctors' decisions to 'encourage' treatment, long after benefit of such treatment is an altruistic or financial decision on their part.
While Dr. Bernstein's concerns and mine may differ, ultimately, our question is the same. His, is, ultimately, at what point do we stop treating and begin palliating. Mine is the equally difficult one of convincing doctors to consider that what is in the patient's (and by association, their caregiver's) best interest might just be "less is more".
(My outlook is obviously skewed toward the patient AND the caregiver, since I am not only an oncology nurse, but the spouse of a person with cancer. Distributive justice has a completely different meaning for us.)
One of the mechanisms I have witnessed which prolongs the "hopeful" but, in reality hopeless treatment is the problem of "mixed messages". Most critically ill patients have multiple specialists in consultation beyond the patient's own attending physician. And usually all the physicians on the case never seem to have a chance to get together at one location and at one time to have a discussion of what would be the best professional advice for the attending physician alone to present to the patient and family. And so, without this opportunity to develop a consensus, what happens is the propagation to the patient and family of "mixed messages" each from the various consultants. Some specialists may present a pessimistic prognosis, suggesting only palliative care and some may present a "sort of" optimistic prognosis and that further procedures would be medically reasonable. The patient and family is thus left with an argument that Dr. B's negative prognosis must be in error because Dr. A had presented them that optimistic prognosis and, of course, that optimistic prognosis is the one that will keep the "sliver of hope" alive. And what about the view of the attending physician? What else can that doctor say when confronted by the patient or family with the optimism by some of the very consultants that he or she selected for the case? It's tough to go against the decision of your consultants when standing in front of the patient or family.
There should be strict rules, like football, in this game of communication that requires a "huddle" between the attending and the consultants first and then only the attending physician "throws the pass" (presents the consensus) to the patient and family. Does this happen? Not really and thus "mixed messages" is a major defect in the medical management of the patient in this era of multiple procedures and treatments available but not necessarily always appropriate for that patient. Have either TAM or rapnzl rn or my other visitors have experienced this "mixed messages" issue? ..Maurice.
I guess I slightly experienced that. With a patient with terminal cancer, on physician was intending to perform a procedure. When a (very brave) nurse phoned and told me it was happening, I spoke to another physician and asked if it was pointless basically - and he said he would recommend against it. We chose to cancel the procedure.
But I find myself disagreeing with your recommendation of how to handle this.
While there might be mixed messages - that is because there are mixed opinions. I'm all for doctors discussing the case, I wish that would happen more.
But as the patient - I'd like to hear everyone's opinion and make up my own mind. Not have the physicians take a vote, and I only get to hear it from one physician, and never hear the opinion of those who were outvoted.
Again, we're adults, we can make up our own minds. If I'm being cared for, and paying, a bunch of physicians, I want to hear what each one has to say. Not, some version of that edited by another physician.
Now, I agree. If the doctors disagree, that can make the patient's decision harder. But that doesn't make it wrong that they hear those opinions.
TAM
TAM, you make a reasonable argument from a patient's or family's point of view, understanding and experience but obtaining decisions about prognosis and appropriate management from a group of specialists can be complicated and beyond the capacity of patient or family.
What I am writing about is the fact that specialists are often making decisions based on their own medical/surgical knowledge and experience in their own specialty. They may not be aware of the clinical details of another specialty that must be considered and this is where a discussion by the entire group of doctors is essential to work out these differences in knowledge and experience. Further and unfortunately, there are self-interests of some specialists which can bias their advice and often the attending physician who called them for consultation is acquainted with the specialists' personalities and interests. Ideally, these issues can be dealt with if all the doctor met together for discussion and came to a common agreement to be presented to the patient by the attending physician.
Ideally,also, one might suggest the better approach would be for the patient and/or family attend this meeting of the doctors and input their own questions and uncertainties. I am not sure that most doctors would feel comfortable arguing between themselves in front of the patient. Actually, this meeting of some of the doctors with some of the family does occur in the setting of a hospital ethics consultative committee meeting. However, usually the doctors are already in agreement and the conflict regarding decision is set by the family.
TAM, I still would say that presenting "mixed messages" to the patient or family by the various physicians on the case is a bad way to provide constructive insight for decision making. The attending physician should be the only one to convey a consensus and defend it. But, unfortunately, that isn't generally happening. ..Maurice.
Maurice, you say "obtaining decisions about prognosis and appropriate management from a group of specialists can be complicated and beyond the capacity of patient or family."
Well I don't think it's beyond my capacity, for example. I'm sorry, but this again sounds like "taking care of" the patient more than many of us wish to be taken care of. Some of us are pretty smart, given the chance.
I do agree the doctors should discuss the case between themselves. I have seen where specialists only look at their own "piece" of the patient (e.g. a kidney) and don't take into account the rest of the patient. I once had a cardiologist tell me "Unfortunately, we each only look at our own piece" and my response was "Well the kidney guy's piece isn't doing its job and it's upsetting YOUR piece".) So a meeting between the doctors, to make sure they all take the entire patient into account, is an excellent idea in my opinion.
I personally would love to attend that meeting, but I understand that the doctors would very likely be too uncomfortable to speak openly. I remember very clearly, a TV show (Hopkins) that showed real life in the hospital. In one such conference, one of the physicians said bluntly "I think we should let the child die". I'm sure he wouldn't want to do that in front of the parent. In fact, he was wrong, the child was treated and recovered. But it was his honest opinion. So I can accept giving the doctors space to openly disagree with each other.
But, if after speaking to each other, there remain differing opinions, I want to hear all of them. In fact, I want to see all the specialists, so that if I have a question for them, I can ask it. I do not need the attending physician to "protect" me from the specialists. Again, that strikes me as somewhat paternalistic.
If, after speaking to everyone, quesetions remain, then the attending can certainly give more explanation.
TAM
TAM, so what should a meeting between the doctors have as its goal? Agreement or disagreement? Remember, treating the patient appropriately should be a unified approach by all physicians involved. One doctor cannot go his or her own way. Unfortunately that is precisely what happens currently as doctors express their views independently directly to the patient and family. This adds nothing but confusion and conflict to the decisions to be made by the patient and/or family. From the view of a hospital ethics committee participant of many years, I find that each specialist communicating their own views directly to the patient/family without previously integrating such views with the other physicians on the case, "mixed mesaages" is really not in the patient's best interest and is the reason some cases end up with an ethics committee consult. As for the attending physician to provide the family with a conclusion of the physician conference, there is no reason why the arguments of the alternate views discussed could not be related to the patient/family and the physician then answer the questions which are asked. But the physician, one physician, should present the consensus and explain and answer the basis for the conclusion. And, well, if there was no consensus after the physicians' meeting.. ah! there is always the hospital ethics committee to help. ..Maurice.
I think the goal of the physician's meeting be neither agreement nor disagreement - it should be understanding.
Understanding of the other physician's perspectives, and understanding of how the disease process is affecting the entire patient.
That understanding may lead to agreement or disagreement.
I do not have faith in any person necessarily presenting an opposing viewpoint completely objectively. If my attending physician said "I think we should let you die now. But Dr. B the specialist thinks he can treat you and you will live" I'm sure you can guess what I'm going to do. Bye - send in Dr. B.
So I suspect the attending physician would be more likely to say "Well, one specialist seems to hold on to some shred of hope, but all the rest of us think he's wrong and unrealistic - so this is what we think you should do".
Quite a difference. Not disparaging the attending physician, I just think it is human nature.
As the patient or family member, I don't care if it's a bit confusing. I'll figure it out eventually. And if there really are differing opinions between the doctors, then it seems to be that perhaps should end up at the ethics committee.
I'm afraid I still disagree with you. I "hired" a bunch of physicians, I want to speak to all of them. Myself. And I would be quite insulted if an attending physician felt he was entitled to filter their input and opinions. I feel I am smart enough to understand multiple physicians speaking to me. Might it lead to an ethics committee? Maybe. But then, maybe it should.
Now, I suppose you can treat some patients a bit differently than others, depending upon what they want.
My elderly uncle, for example, didn't want to make any decisions. He just wanted his doctor to tell him what to do. He would have been quite happy with your scenario. He did do just as his doctor told him. However, near the end of his life, he wished he had made some different choices - he would have declined some treatments, even though the prolonged his life some. So I'm still not sure he benefited by not hearing multiple opinions - although it was his choice.
The attending can talk about it first to me as the patient, that's fine. But I still want to speak to the specialists also. I suspect it's probably my right as a patient. I understand you don't wish it to be so - but isn't it my right as a patient to speak to and hear the opinion of any physician who consulted on my case?
By the way, I am not really arguing in favor of futile care, I do believe there is a time to stop, and do not blame the physician at all for that. I believe it's very hard for them as well - they have to admit 'defeat' and I'm sure, to some extent, physicians often feel they have failed. Even if it was not reasonable to excpect them to succeed, no one likes to lose.
TAM
TAM, it is not to the patient's nor family's benefit to hear independent and physician-personal prognosis from each physician whether separately presented or in one session in order for the patient or surrogate to make a decision. The human body is one anatomic-physiologic-pathologic entity. Disease in one system can affect a disorder of another system and vice versa. As many specialists will do is to prognosticate their own specialty and, unfortunately at times, additionally, based on their own personal biases or personal interests. Some specialists don't want to be the one to have precipitated the patient's death by denying the patient their specialty service.
It's unfair to subject the patient/family to the potential of "mixed messages" It is my opinion that it is more fair for a final best decision by the patient to hear a summary of the underlying multi-system disease or diseases and the pros and cons of the various approaches to further management by one physician, the patient's admitting physician who will speak the consensus of the other doctors involved. And a consensus must be reached at some point so that the appropriate treatment can be begun or continued without hesitation or conflict. It is because of the latter developments, that the case ends up being an ethics committee consultation not for the committee to make the final decision but for mediating and facilitating a decision which could have been made earlier without them if everybody got together in discussion and the patient/family presented with a consensus prognosis and an approach for what's next. My opinion is that it is a rare event for "mixed messages" to be something to improve decision-making and end up as a benefit for the patient. ..Maurice.
Well I entirely agree with you about each specialist just looking at their own 'piece' of the patient. Yet still, I, as the patient or family member want to speak to each physician, and make up my own mind. I have been in that situation (family members) multiple times, and have done that, and can understand and make my own decision (if the patient i not capable). And I think I made the right one in each case. And yes, I did get a few conflicting opinions along the way.
The thing is, going towards getting away from paternalistic attitudes and becoming patient centered, what will you do with a patient like me? Create a procedure (only the attending talks to the patient) that denies me what I feel is mmy right to speak to the other physicians? (Still wondering if it is my actual right really). I think that would show me disrespect, and is in a way disrespectful to the specialists, that they are not allowed to express their opinion.
Now, I have no objection to all the doctors discussing it amongst themselves - if only. It seemed basically an act of god to get doctors to actually talk to each other about a case. Not read a chart... talk. Speak. On the phone, or in person. Rarely happened, drove me nuts. I'm on your side there. And if there is a concensus, no problem.
If some still disagree though, I want to hear it. Maybe the guy in the minority is actually right. If there are multiple treatment options, I want to hear the pros and cons, and choose for myself. With the physicians advice, of course.
Now, I think perhaps you need to not have some hard and fast procedure, you need to figure out the patients needs. My elderly uncle - he's all for your plan. Me, you wouldn't want to deal with me if you tried to implement that plan, I wouldn't put up with it. We're all different. We have different needs for many things, including information and decision making.
I don't want you all to improve your decision-making and enforce that on me - I want you, and the other physicians, to help me decide. Patient-centered.
TAM
TAM, I am not saying that the patient or family should not be able to talk to one or all the specialists on the case as they desire. In fact, that is usually what is happening now. I am saying that if each doctor expresses a different view and a different prognosis to the patient and family that isn't very helpful for decision-making by the patient and may disorganize general attempts at future management. And in all cases, it is the patient or surrogate who makes the final decision. It is the doctors and hospital which either accepts the request or decision and follows through or in the case of requests which are beyond the medical/surgical standards of practice, unphysiological or beyond the moral values of the doctor or hospital, the patient must be assisted in attempting to find another physician or hospital that would follow the request.
Unanimity of opinion and prognosis sometimes is not possible but one path needs to be started with the goal of beneficence for the patient whatever the stated prognoses. ..Maurice.
OK, perhaps we can come aound to agreeing more, I am glad.
I am all for the physicians meeting, and coming to a concensus if possible, taking into account each others perspective.
But, if at the end of that, some physician still has a dissenting opinion, I still think that the the patient (at least if it's me) should be able to hear that, and take it into account. If they need more explanation, the physicians can try to give it. If it needs the ethics committee, ok. The fewer times that is necessary the better.
And sure, what the patient wants does have to fit within acceptable practices - I do not think patients should just be able to 'order up' any treatment they want.
Thank you for you patience in this discussion.
TAM
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