“There’s almost always, in every medical circumstance, one more thing we can try,” says Dr. Julie Bynum. But less often do we talk openly about whether it’s worth trying. Dr. Bynum is a gerontologist at Dartmouth’s Geisel School of Medicine and co-author of a study that found that while Medicare patients are increasingly choosing hospice or palliative care over heroic measures in their last days, many still go through futile hospitalizations and treatments first. Why is that? Dr. Bynum told the Los Angeles Times, “It’s hard for a doctor to say ‘I have one more thing I can do, but it’s not a good thing.’” She explained, “We’re pretty fearful of taking away hope.”
Reading this I found myself back in time—at one of our Monday morning staff meetings in the regional cancer center where I served as the staff medical humanist. Mondays at 8am, staff would review the upcoming week’s schedule: new patients, returning patients, patients whose prognoses were changing, for better and for worse. On that particular Monday one of our oncologists announced he had spent the weekend in search of “one more thing” to offer one of his patients. Studying the printout of the clinical trial in his hand he looked weary—frankly exhausted. I lay my hand on his. “Remember,” I said, “your oath was to do no harm… not to cure cancer.” He mumbled his thanks, quickly turning away as his eyes began to fill with tears.
It’s easy, sometimes, to forget that our doctors are human, too. They want to do the best they can for us. But in some cases, the “best” may be a candid conversation about what can be gained—if anything—from trying one more thing.
As a patient, you may have to give your doctor permission to tell you the hard truths. A doctor who is invited to be honest will be better prepared for these difficult conversations and to answer questions about prognosis itself, as well as the advantages and disadvantages of treatment. An understanding of all these factors is critical to helping patients choose the course of action that is right for them.
Judith Hills MD,MS
It is so true that patients often need to give the doctor permission.Patients are not used to giving permission to doctors
so this is a wonderful point.
Amelia Silver
This makes a very important point so succinctly. Doctors are often burdened by their self-appointed or societally-appointed role as savior, person with an endless bag of tricks.Only their patients (and perhaps their colleagues) can free them from this unrealistic role. I know as a patient I want the whole story, which includes the option of ending treatment.
Max Vergo
Everyone grieves in their own way… patient and doctor. As a recent medical oncologist and current palliative care physician, I can say that I have known many oncologists that “love” by “treating” as that is what they have been trained to do. In addition, there is the assumption on the part of the medical oncologist (or substitute any medical specialty here) that if a patient shows up and asks “what else can be done” that they are willing to accept whatever therapy is conjured up almost regardless of risk to quality of life. It seems to those of us that are not sick that nothing could be worse then death, but I have come to the understanding from treating many patients who are dealing with serious medical illness that this is not a certainty. As physicians, we need to better learn how to express our grieving to patients (ie. “You don’t know how much I wanted to offer you something today that would meet your goals, but to my dismay I am not sure I have a reasonable treatment option. I am so sorry.”) And as patients, I think we have to learn how to be brave enough to consider what is worth hoping for besides cure or significant life extension and tell our treating physicians so they can help us make the best possible medical decisions to meet those hopes. It is about connecting genuinely as two people struggling from different perspectives to make the best of a bad situation. It’s all about being human with each other.
Anne Gatling
We don’t often think of physicians as grieving or struggling, but as fellow humans, of course they are. We need to give each other permission with many things in life in order to genuinely connect with one another. May we all have as articulate and thoughtful a partner as Dr. Vergo.
Judith Hills,MD
Max, you said this in a wonderful way. I can not add anything but to say Thank You.
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