Can “Doing Everything” Be Cruel to Clinicians?

By Marjorie Stiegler on February 9, 2015 in Health Policy, Medical Decision Making, Patient Safety and Quality, Second Victim
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"Doing Everything" is a dark and dangerous idea

Earlier this week, I read a moving piece in The New York Times called “When ‘Doing Everything’ Is Way Too Much” by Dr. Jessica Zitter.   She explores the unintended consequences of the shift from paternalistic medicine to what we call “patient centered care” today, in the context of the “do everything” advanced directive.

(Image credit: Andrea Bruno; The New York Times)

The subject of her essay is “Vincent” – a patient “being eaten away to a degree I had never seen,” for whom decisions were based upon an outdated document, hand-scribbled:

“To any doctor who will take care of me in the future: do EVERYTHING in your power to keep me alive AS LONG AS YOU POSSIBLY CAN!”

She says: “In trying to honor Vincent’s autonomy, we abandoned him in hell…I am sure that Vincent could not have known what he was setting himself up for when he wrote that note…that we could keep his body going even while it was trying its hardest to die. And now he was suffering, with every lonely hour in an ICU isolation room…”

Also worth a read are the nearly 200 comments (at the time of this writing).   One person suggests that having to care for patients in such hopeless states is “cruel” to the medical professionals who must treat him.  This touched me especially, because of the recent onslaught of emails in response to my JAMA article about the second victim effect.

Shifting gears, one commenter wonders “how many tens or hundreds of thousands of dollars his nursing home, doctors, hospitals, ambulance services, pharmacies and all the other medical professionals must have raked in as they tortured this poor man for ten years” and calls it “Shameful.”  This raises the important point that end-of-life is often the most expensive, and might be a good target for cost containment, but it also seems to imply that somehow the medical community at large wanted to continue to subject him to “treatment”, when the author’s position is clearly otherwise.

And this comment to modern-day physicians: “Whether you like it or not, whether it shocks you or not, whether you agree with it or not, your only job is to accommodate the wishes of the patient. In that way you are no different from a car mechanic or a house painter: you are there ONLY to provide the services that your customers request.”

 

What’s your take?  In the name of patient-centered care, is the role of the physician reduced to that of a customer service agent, accommodating patient requests, no matter how they conflict with ethics, the laws of nature, or “informed consent”?

 

2 Comments

  1. X February 9, 2015 Reply

    I think this is the central ethical problem of modern medicine. With so many tools at our disposal, many physicians are not able to confidently say that a therapy will not succeed, and perhaps some believe that there are no longer any lost causes. We rely on studies for which the highest standard of evidence is 95% certainty (ie, not 100%), but if, having estimated only a 5% chance of success for a given therapy on a given patient, would many physicians deny that therapy to that patient? The highest ethical imperative, contained within the Hippocratic Oath, is to do no harm. It seems many of us have forgotten this, employing ever more advanced technologies to chase ever more slim chances, betraying our own humanity in the process. And then, having given patients false hope, we absolve ourselves of blame, because the patient asked for us to “do everything.” Our calling is to do the right thing.

  2. Stefani Daniels March 17, 2015 Reply

    I read that article and thought ‘shame’ on that physician. He could have refused to treat the patient to the extent that he interpreted the ‘note’ and found someone, perhaps, less ethical, to take over and rake in the dollars. Instead, he continued to treat a dying patient. Where was his humanity?

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