Sunday, May 5, 2013

The Patient and the Facts

There is an interesting piece today in the NY Times by a Resident at one of the Harvard Teaching Hospitals. I guess it has become fashionable for residents to now discuss the insight they have obtained halfway through their training process. The responses are more telling than the piece, and they are worth a read. Namely the consensus is the person is quite naive. Why, because they felt that as an Intern they managed to convince Resident s and Attending to change a protocol for some terminal patient. Was that good or bad? Well it all depends.

Statistics are often used, by physicians and patients, to justify actions. Take some of the recent melanoma therapeutics. Fifty percent of the patients last an additional six months. Yet some 20% keep going on. Thus if you are one who has the choice for the drug, what do you bet on? Frankly the bet only applies to a large cohort, and never to a single patient. You just do not know, what will happen will happen. There is always a bit of fatalism.

However people like Kaplan managed to change the survival for Hodgkin's disease, It went from 0% to almost 90% with radiation and multi drug cocktails. Yet along the way there were many failures and distressed families. Yet as a species we learned and made progress.

All too often it is the family who demands all life extending actions, often at massive costs and incurring great distress for the patient. This is a difficult issue, it involves the ultimate demise of all of us and all too often our own demise is denied, for good reason.

As the author states:

And yet studies have shown that patients almost universally prefer to be told the truth. If physicians cannot deliver the hard facts, not only do they deprive their patients of crucial information, but they also delay the conversation about introducing palliative care. 

Many times the physician just does not know. Certain malignancies, such as prostate cancer, may be indolent or aggressive.  The physician really does not know, at least at this time. The "truth" is that one just does not know. On the other hand a Stage IV melanoma with brain mets may in almost all cases be terminal. Should the patient be told, yes, and should the family, yes. Is there much to do about it, possibly, but frankly what may be done will be to add to a data base of understanding ant note necessarily be curative.

The author concludes:

The patient’s condition got worse. The tumor grew to the point that we had to put in a tube to deflate her intestines. She developed clots in her lungs, but we couldn’t treat them with blood thinners because she was already bleeding internally. She had to get all of her medications and nutrition through an I.V. It was clear to the team that the more humane thing to do would be to focus on her symptoms and keep her comfortable rather than trying to extend her life. But there was nothing we could do to uproot the horror of irrational optimism that had spread through her body like a cancer uncontrollable. 

 In the case of colon cancer mets to the liver one sees the ascites expanding the abdomen, the severe discomfort, and the care is at best palliative. This was know for centuries, and the author seems to be grasping this for the very first time. There is the perception that the physician must treat each new symptom of the terminal illness rather than just making the patient as comfortable as possible. That is why the most insight to this issue resides in the commentaries when discussing the lack of experience of the author.