There are myriad examples of the effects of attitude and hope on health outcomes. Most of you have probably heard allegorical evidence of this, journals have reported similar findings, and placebos may be one of the most visible examples that positive thinking results in better outcomes.
Physicians must walk a thin line as they balance imparting hope and painting reality. A typical doctor does not want to fail, give up, or admit defeat. This is part of how we are trained and a product of the personality types that are often drawn to medicine. Because of this, patients and families are not always left with the most accurate picture. Even when provided with the facts patients and families are rarely prepared to make any decision other than ‘use any and all means necessary.’ I have heard several examples lately about how, especially during end of life care, this often leads to overtreatment. Overtreatment is almost always synonymous with undue suffering and undue cost. The modern version of the Hippocratic Oath discusses this related balancing act as the “twin traps of overtreatment and therapeutic nihilism.”
As a general rule, our society is terrified by the end of life. It is reasonable for a person to want to receive any and all treatment that may extend their life. Unfortunately, some of these treatments end up actually shortening the end of life or, more frequently, causing a drastic decline in the quality of the final period of life. On the other hand, there are certainly times when these treatments work brilliantly. So, what are we supposed to do?
It seems that patients and doctors are both terrified to have these conversations, so government has begun to step in. According to an excellent New York Times article, laws have already passed in California and New York which require physicians to provide options for pain management and palliative care along with information on prognosis and further life-sustaining treatments.
While I don’t think that legislation is the best way to deal with this issue, it is absolutely an issue that needs to be dealt with. The truth is that this conversation does not happen nearly as frequently or as thoroughly as it needs to. People have every right to continue potentially life sustaining treatment as long as they would like, but I also firmly believe that they have the right to accurate information regarding their prognosis, side effects, and palliative care options. Because this decision is often extremely difficult when the patient is often already suffering or scared, the initial phase of this conversation should be initiated before things take a turn for the worst. Doctors and patients alike find this a difficult conversation to bring up. Therefore, doctors need training in order to better have these delicate discussions. There is more to treating a patient that extending their lives. While medical schools have begun to incorporate these ideas into their curriculums slowly, it cannot be incorporated soon enough.
A quick aside about cost: The vast majority of our healthcare expenditure goes towards care during the final stages of a person’s life. If the healthcare system finds a way to better approach this time period, we would not only be improving quality of life for patients and their families, but also saving a considerable amount of money.
Let us continue to treat each patient as they are a close family member and never give up hope that they can be cured or their life extended. However, we shouldn’t stop there. We should also ensure that hope does not get in the way of educating the patient so he/she can make the right decision regarding treatment. In order to do this most effectively we need to educate physicians better in this area and encourage them to have these discussions before the decision is further complicated with serious illness.
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