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Is Doing Nothing Sometimes Doing More?

Kendracampbell572x725Kendra Campbell -- I’m currently re-reading the famous book, The House of God, by Samuel Shem (Steve Bergman’s pen name). I read this book many years ago before ever starting med school, and I really enjoyed it. However, now that I’m doing my clinical rotations, I’m enjoying it with a new found appreciation, and I’m really starting to understand all of the subtleties and nuances of the story. I highly recommend this book to anyone thinking about going into medicine, med students currently doing clinical rotations, doctors, nurses, and just about anyone who enjoys a well written novel.

In the book, which focuses on the lives of interns in particular, the name “gomer” is given to the elderly, terminally ill patients that are always filling up the hospital, and who never seem to die. In fact, the first “Rule of the House of God” is that “Gomers don’t die.” The book gives an alarmingly accurate portrayal of how the main character, an intern, begins his internship with the medical student mentality that it’s possible, and in fact the doctor’s duty, to do everything possible to save a patient’s life. A much more seasoned resident tries to explain to him that for the gomers, this is not the best approach. Although the intern resists the advice of the resident at first, he soon learns the harsh reality that there is much truth to this approach.

Eventually the intern takes the resident’s advice and instead of “doing everything possible” to save the gomers, he does the exact opposite: he does nothing. Instead of running huge batteries of tests on the gomers, he doesn’t run a single one. Instead of administering all the medications and treatments that “medicine and science” would demand, he gives them little or none. And what’s the amazing result? The gomers end up doing way better on his watch. In fact, he becomes known as the hospital’s best intern, as he develops an amazing patient care track record.

I recently had an experience with a patient that was frighteningly similar to one described in the book (some details have been changed to protect patient confidentiality and to demonstrate my point). An elderly patient came in with the simple complaint of numbness and tingling in her arm. A chest x-ray was performed and showed a mass highly suspicious of lung cancer in the apex of her lung. A mediastinoscopy was performed in order to better visualize the mass and perform a biopsy. After the procedure, the patient developed a large hematoma and had to be rushed back into the OR to stop the bleeding. Because of blood loss, she ended up becoming very anemic, but couldn’t be transfused because she was a Jehovah's Witness. The patient also developed pleural empyema and eventually a chest tube had to be inserted. The chest tube ended up causing a pneumothorax, which had to be corrected. After the pneumothorax, the patient developed subcutaneous emphysema. After all this, she eventually developed a nasty case of hospital-acquired pneumonia. The story goes on and on and ends with the patient having a very lengthy stay in the hospital. In addition to that, the mass turned out to be inoperable and the patient eventually left the hospital with the same complaint that she came in with, in addition to having to deal with all the complications that arose from all the procedures!

While this is an extreme example of complications arising from hospital care, I think it serves to bring home my point. Would this patient have received better care if her doctors had simply chosen instead to do nothing? This is just one case, but I could describe many others where a very sick patient’s life was extended by a few weeks, only to cause them to endure countless complications and pain. How do we know when doing nothing is doing more? How and when do we make the decision to institute hospice care? I know hospice care is not “doing nothing” (actually, in some ways, it is doing much more), but it is a different (and I think in many ways better) method of approaching and caring for the terminally ill.

I have so many thoughts on this, but I’ll save those for another post. I’d love to hear what all of you think. Do you think choosing to doing nothing (in terms of medical treatment, not necessarily patient care) can ever mean doing more for the patient?

October 13, 2008 in Kendra Campbell | Permalink

Comments

I think the choice belongs to the patient.

None of the 'side-effects' in the case you described are particularly unusual. If the patient had known the possible outcomes ahead of time, she might have chosen to do nothing. Or she might have preferred to give it a try. She might have wanted the possibility of attending her grandson's graduation in three years, or she might be ready to pass on.

I'm not talking through my hat here. When Peyton was dying, the biggest problems I had with medical providers was when they took it upon themselves to make decisions about testing and medication. Surprisingly (or maybe not), it was always the best and most respected doctors who always consulted me and Peyton. It was the least experienced who made decisions without consulting us or even in some cases without consulting Peyton's GP.

Now I'm not so stupid that I don't realize that the good doctors were also making some decisions because they couldn't possibly present every possible option and describe every possible outcome. That was where their experience and knowledge were put to use on our behalf. And that was appropriate.

Posted by: Tom Davis | Oct 13, 2008 11:59:34 PM

it's up to the pt.

Posted by: sms | Oct 14, 2008 5:04:24 AM

its always ultimately up to the patient. we as doctors can suggest a best course of action but it is the patients informed consent we need in order to proceed with our treatment plan, whatever it may be. and hindsight is always 20/20.

Posted by: Intern | Oct 15, 2008 8:37:28 AM

I think it depends on the age of the patient as well of the manifestations. I lost my great-grandmother at the age of 6 from cancer. Didn't have the whole details but from what i gathered from my mum,they shouldn't have operated her and just let her live the remaining few months instead of suffering after the operation. So i guess yea sometimes it's just better not to do anything. :)

Posted by: missy | Oct 17, 2008 2:40:57 AM

I was told by a doc who has been practicing more years than I've been alive that the clinical side of "First do no harm" is "First do nothing."

We're anxious to intervene, because many of us believe this as why we train to be doctors.

My bias is deep and foundational here, afterall I'm choosing to study naturopathic medicine rather than "conventional" medicine. That said, I'll touch on a point that was brought to my attention by a woman licenced as a doctor and a midwife. "Interventions tend to lead to more interventions."

She was speaking in the context of the birthing process, and the case you discussed earlier is another good example of this point.

Now that I'm in clinical rotations, I've discovered something I hadn't considered when I dreamed of becoming a doctor: patient's goals and provider's goals don't necessarily match.

Sometimes patients want explanations, ideas, options or just to be heard... they don't always seek treatment.


Posted by: michael stanclift | Oct 19, 2008 8:13:46 PM

I know I've had experiences where going to the hospital left me with more frusrations(mspelled) than answers some doctors when that can't find answers to whats going on assume your a drug seeker in my case asimple blood test would have given them the answers they needed to treat me it turned out to be my liver failing but they would check my pancreas my gallbladder my apendix nothing never once checked the liver I went from Dr to Dr until one checked my liver and found the problem I still see this Dr to this day and my progress is very good my advice is listen to what the patient is actually telling you and stop looking at the bottom line and stop thinking everyone is drug seeking because not all of us are

Posted by: susan johnson | Oct 21, 2008 3:01:22 PM

Good points, all. I'd really like to see the concept of "informed refusal" taught in addition to informed consent, whereby clinicians would present "don't intervene" as a real and viable option in all non-emergent situations - along, of course, with the risks and benefits of that option - instead of just being trained to give the patient enough information to procure consent. Birth is my field of interest, as well, and I see this problem increasingly with hospitals across the country adopting no-VBAC (vaginal birth after Caesarian) policies: in effect, they're forcing women birthing in their facilities into accepting an invasive procedure whether they agree that it's a good option for them or not. Not good medicine.

Posted by: Susan Way | Oct 21, 2008 5:55:14 PM

I think you touch on a real gray area of the moral compass. As has been said, it is ultimately up to the patient to decide whether or not for treatment. But how many patients are being pressured to make a semi-informed decision? Or, how many doctors are looking at their bottomline and go over the top on unnecessary treatments?
I'm a student studying surgical technology, so I don't have a long history in healthcare. But what I'm starting to see is the ethical question of surgical procedures for patients who might be better off being made comfortable for the remainder of their time in place of a procedure that fixes a problem they have, but doesn't heal them and they die anyway.
It seems very wise,as Michael pointed out, that "First, do nothing" can be a very good place in which to start treating a patient.

Posted by: Dwayne Tank | Oct 21, 2008 6:03:58 PM

Great book rec. Thanks.

To treat or not to treat...this is a touchy subject. Balancing patient/family expectations that something, anything, everything must be done to right the wrong in the patient with the sitting on ours hands to let time take its course. As care providers, the difficult choice could mean knowing less in more, and possible more difficult helping the patient and family understand this way of thinking. Every case has unique circumstances, but would most patients and families be able understand and concede?

I am new to the ED, but my opinion has already begun to edge towards a more hands off approach with terminally ill. By trying to change our societies expectations for superman-like care, we may end up being the hero in the end. We'll see.

Posted by: Doug | Oct 22, 2008 8:07:07 AM

I used to think it would be up to the patient. However, I have had the AWFUL experience of being a patient recently during a very frightening experience of collapse. During my hospital stay I was horrified to find doctors speaking to me like I knew nothing ('its a bit of a bug' - yes, but which bug?) and when I asked questions I was told 'dont worry yourself about it, don't get distressed, we're the professionals' etc.

I felt disempowered and unable to make decisions about my care. I didn't know what was going on most of the time and became frightened to ask incase I got 'shushed' again. Its bizarre - in my uniform I'm happy to give patients information and fight their cause. Put me in pajamas in a hospital bed and I lost that ability.

I know from my professional experience it can be hard to gauge the amount of information a patient should have to make a decision, but they do need enough to make their own choices. Its a completely different experience to be ill in a hospital bed - I know my care of patients will improve as a result of this experince.

Posted by: Gracie | Oct 22, 2008 9:02:04 AM

Put it this way it may be you what would your answers be then?
You in the bed not attending it or watching as a relative!

Posted by: dimblo | Oct 22, 2008 10:48:42 AM

This issue really hits home for me....so please excuse the long post.

I am an M4 and am currently doing an inpatient rotation with a family medicine team here in Wisconsin. Based on my experience - this FM team has done an excellent job of offering frail patients the option of comfort care measures as alternatives to tests/interventions that are invasive, painful, (often wildly expensive) and unlikely to significantly change their outcome. This team seems more attuned then the general medicine inpatient teams I've been on. I guess it helps they generally have relationships with the patients outside the hospital as well. However, it is really difficult to watch families in denial choose invasive/painful treatments and tests again and again for their loved ones.

I recently returned from a Palliative Care Rotation in Norway. In Norway, when a patient is elderly and frail and no longer the medical decision maker, their doctor makes the decisions. The family is included in the discussion of course, but ultimately choices are the doctors. At first I found this shocking. Now I'm beginning to think it's not such a bad idea. As my Norwegian mentor said, "look, asking families to make such difficult decisions is an unfair burden on them when their real role is to grieve and be at the bedside. Families often lack the medical background to understand the complexities of multi organ failure at the end of life. It is a burden to have them make choices they may later feel guilty about. We lift the burden." A bit paternalistic for the USA, but food for thought -eh?

Posted by: Sarah | Oct 22, 2008 11:52:34 AM

As a doctor we must do something that give benefit to the patient and do nothing that could harm the patient.That's why there are some indication and contraindication of what we do to the patient based on clinical diagnosis.There are the law of Beneficence and Autonomy as our guidance when we treat patient.

Posted by: Tia | Oct 22, 2008 9:14:54 PM

i think the choice ultimately lies with the patient. if we were to give up on all terminally ill patients, i dont think we'll ever be able to come up with new techniques,be it surgery or medication, in order to treat a terminal disease. a disease is terminal only until we find a cure for it. the decision to try is for the patient to take though.

Posted by: ritu | Oct 23, 2008 6:14:40 AM

I haven't really studied oncology and chemotherapy yet, but I've always had in my mind the idea of providing better quality of live instead of fighting death.

Physicians have always had the idea that death is the enemy, and though none of us want to die or want our patients to die, what I think we should fear the most is not only disease, but the signs and symptoms diseases cause us. That's why, I think if I ever have a patient like the one you talked about, without any serious complaints, I would rather explain to them what was going on and recommend them to enjoy the gift of life because it's running out for everyone of us one way or another anyway. If she decided to know her disease better, to go for chemo of stuff like that, that we know it's going to deprive her quality of life, so be it. I, as a physician, caring for the well-being of my patients, think I wouldn't agree that much, and maybe I'd refuse, but maybe I would just help her in the way she'd wanted me to.

Bottom line, it's hard for me to anticipate exactly what I would do in a situation like that, but I hope that 'being a hero' and 'fighting inevitable death' won't ever be more important for me or my patients than to enjoy the things they/we love to do and just be happy while we can.

Again, thank you for your post Kendra, I can't wait to look for The House of God and read it :)

Posted by: Daro | Oct 24, 2008 8:25:29 AM

It's a "thin line" to decide what to do. It depends upon the case surely, but if i were in such a difficult situation, i'd try to do my best, because waiting for the right decision sometimes could be loss of time and doing nothing is so difficult for me in a situation somebody needs my help!. of course sometimes doing nothing is the best choice rather than giving harm to patient. it's very hard thing, i hope we'll decide best for him in such a difficult time!

Posted by: Yeliz | Oct 25, 2008 1:49:06 AM

I know that doing nothing sometimes is doing more and the choice is ultimately up to the patient but isn't doing nothing technically doing "negligence"? I mean, how can we be sure it is really nothing.

Try to look at it this way, the doctors give all the diagnostic tests, then they found that nothing could be done. On the other hand, they wouldn't know that it was nothing if they didn't do the tests. What if the tests revealed a something instead of a nothing? Won't then the tests be worth it? I mean, I'd rather undergo the tests and find them all negative and not have a single one and have all those illnesses.

Posted by: nadine | Oct 25, 2008 6:26:04 AM

what i would like to add here is the case being discussed by u have two different approaches the 1st one being as an allopathic doctor who obviously cud not belive in doing nothing as we being from the feild are there in the hospitals for providing such interventinal facilities knowing the side effects and explaining them to pateints and leaving the desicion on them and most of the pts ending up with taking the option, as we tell them either this is the option or we shall leave the the condition to proceed towards worst and their trust in our words that without intervention the condition wud go to worst is the only factor making them opt for the interventional process . nothing is wrong as the pts trust doctors and they provide best according to the knowledge they have from their books of medicine but the second approach is to take the case as not the one to be provided with the best of allopathic medicine but to provide with the best possible in this world means to advice all kinds of healing process existing in this world and make them as a part of treatment which wud than include healing process from all part of the world for one coommon disease being treated differently in diifernt part of the world which might inclde spiritual healing and meditation and manymore which basicallly include doing a lot while doing nothing and ofcourse if treats the pts or decrease the pain wud b the best option ...........................

Posted by: rani bai | Oct 26, 2008 1:04:09 AM

I'll try to find the book and read it.
As a doc i can't imagine doing nothing to the patient if he/she needs the help that we must give.We do nothing when there is nothing to do. I'll try my utmost to help the patient.Yes ofcourse some of the procedures are painful and what more painful can it be to intubate a patient. Just imagine someone passing a tube in your trachea how much it would hurt BUT in times of need we have to perform it and the patient survives. Last but not least,we as a doctor can only dx,treat and reduce signs and symptoms BUT we can not give someone life(thats upto GOD to decide).

Posted by: mujtaba | Oct 27, 2008 9:53:17 AM

Loved "House of God" ! i actually had a doctor tell me n o t to read it...hah, of course then i just h a d to...have you read the sequel, "Mount Misery"...? Even better than the first...highly reccomended !

Posted by: tfb | Oct 28, 2008 11:12:27 AM

I believe that you should let people be sometimes. We as doctors have this immense desire to try to fix everything that is wrong with the patient but when it comes to elderly sometimes doing nothing is the right thing to do. As in your case, hospital interventions cause a lot of mental stress and sometimes serious side effects. When you have an idea that there is nothing much you can do or what you do is going to cause a lot of suffering and add little time then letting the patient die a dignified painless death is the best option. Many times, we have the power to intervene but the wisdom to decide when to intervene and when not is more important.

Posted by: partha | Feb 15, 2009 6:51:46 AM

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