Monday, August 3, 2015

Accidental Survival from Beneficent Neglect: When "There's Nothing More We Can Do" Becomes Your Salvation

"There's nothing more we can do", according to this NYT article, is a terrible thing for a physician to say to a patient or his family member, even if the intention is much needed candor.

Yet sometimes, a physician's resignation or a patient's refusal becomes the patient's salvation.  There is something to be learned about the futility of many of our treatments and our arrogant ignorance of our impotence in many situations.  Several examples, I hope, will cause physicians to reflect on many of our practices.

A study showing that cancer patients choosing palliative care outlived those choosing aggressive care should have caused a lot of introspection about the possibility that many things we do harm rather than help patients.  How are we to know?  In the ICU, we have several unique opportunities to observe the futility or downright harm of many things we do.

A young woman came to the ICU with mental status changes, an EEG was ordered, and a diagnosis of "non-convulsive status epilepticus" (NCSE) was made.  She was intubated and heavily sedated and treated with every manner of anticonvulsant and CNS depressants and coma-inducing agents.  The EEG continued to show, according to the report, NCSE two weeks later.  The family was told that "there's nothing more we can do" and a decision was made to stop all therapy and withdraw care and prepare to send her to hospice.  This was done, but over the next 24 hours, she awakened and was alert and oriented. She walked out of the hospital later that week.

Think of all the other ways this could have played out, and how the wrong conclusions would have been made about this case.  Had the mysterious EEG signals that were being misinterpreted as NCSE abated or changed, victory would have been declared, we would have tapered treatment for NCSE, and the patient would have survived.

Had the patient died because we withdrew care and provided no supplemental oxygen and ateletasis or ventilator associated pneumonia made her hypoxic and she succumbed to this, we would have concluded that "there was nothing more we could have done" and she died from complications of NCSE.

Had the family insisted that we continue to provide aggressive care, she would have eventually awakened and we would have said "It's a miracle!" or assumed that more prolonged "treatment" did the trick.  Had we provided ongoing care and she died of complications months later, we would have said, "there was nothing more we could do, we said so, what a waste of resources."

It is only because of this series of serendipities that we were able (or better, forced) to to recognize the follies of our ways.

I have had the good fortune the past couple of years to be asked to take care of critically ill elderly patients with DNR/DNI orders to limit aggressive care.  They often have shock (or at least low blood pressure) from sepsis due to urinary tract infection, cellulitis, or pneumonia (the old man's best friend).  I do not believe it is the spirit of a DNR order to withhold vasopressor agents in these patients to support the low blood pressure, but I also don't like to "torture" dying elderly patients putting in central lines and the like.  I have compromised in two ways.  First, I now oftentimes give peripheral vasopressors, my confidence bolstered by emerging reports that this is safer than previously thought and that reports of complications are exaggerated.  Second, I sometimes choose to just ignore the hypotension.  Even in the presence of elevated lactate.  Even in the presence of oliguria.  Even in the presence of decreased level of consciousness.  Even when the mean arterial pressure (MAP) is in the 40s.

And initially I was shocked with what very often happened.  I am no longer shocked.  The other day the hospitalist called me to take over care of a 92 year-old woman with septic shock and decreased level of consciousness and oliguria who was "full code."  I talked to her son and told him she was dying and that we should "treat lightly" and focus on making sure she did not suffer, but I conceded that sometimes patients in these circumstances do remarkably well with this minimalist approach.  Then I totally ignored her MAP, gave her (one) antibiotic, held fluids since she was in congestive heart failure, and wrote for some low dose morphine.  By the time I rounded the next day, she was sitting in a chair eating lunch.  This woman was anti-fragile.  How else could she have made it to age 92, and why would I think that I can manipulate her physiology better than evolution has prepared it to defend itself?

Think of the other ways this could have played out.  Had I given her pressors and she did well, I would have congratulated myself for my clinical acumen, my pursuit of her lactate, my diligent attention to her vital signs and urine output.  Had I given her pressors and she did poorly, I would have said "well, she was moribund, I knew it wasn't going to turn out well."  And on and on.

But most of the time, we do not think that such patients are getting better in spite of us or that we may indeed be doing net harm when we tread heavily.  So these natural experiments in beneficent neglect that eventuate in accidental survival are our patients' salvation.  And if we pay careful attention, they may well be our own.

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