Monday, September 14, 2009

Refining Treatment Preferences For Patients Who Want "Everything"

The Annals of Internal Medicine has a perspective article by palliative medicine communication gurus Drs. Tim Quill, Bob Arnold, and Tony Back which details an approach to discussing treatment preferences with patients who want "everything." When I think of a patient requesting "everything," I typically think of it as a response to a physician who offers the patient the choice of "doing nothing" if the patient's heart should stop or the alternative of "doing everything." Of course, patients pick up on this language and make certain assumptions based on the ambiguity and misrepresentation of these statements. If the patient who has been previously exposed to this type of dialogue is approached during a subsequent hospitalization in a more measured manner, they may still say, "do everything," or some may come up with it on their own. But what does "do everything" mean? Does it mean "I'm philosophically and/or religiously inclined to receive any and all life-prolonging measures no matter what type of suffering I'm going through or how I appear to my family, so keep me hooked up to 4 pressors on a ventilator until all my digits are blue and you're all watching the rhythm strip because you can't ausculate my heart sounds" or does it mean "do everything you can to stablize me so I can go home to die there" or something else?

Quill, Arnold, and Back distill their approach to this common scenario into six easily digestible steps, which includes attempting to 1) Understand what "doing everything" means to the patient, 2) Propose a philosophy of treatment, 3) Recommend a plan of treatment, 4) Support emotional responses, 5) Negotiate disagreements, and 6) Use a harm-reduction strategy for continued requests for burdensome treatments that are very unlikely to work.

The appeal of this approach to me is that it fits very well into how physicians think. The most essential part of this process is to refrain from interpreting the patient's request to "do everything" as a blanket consent for any medical therapy available to humankind. Rather, such a request should be considered akin to a clinical sign that requires more investigation. In step 1, the physician develops a "differential diagnosis" regarding the meaning of "everything" which includes potential affective, cognitive, spiritual, and family related factors. Table 2 of the article suggests appropriate questions that help to delineate the "diagnosis" (ie the meaning of "everything"). In this step, the patient's values, priorities, and goals are revealed. The patient knows these better than the physician. What they may not know (and what the physician should assess) is whether potential medical therapies will be consistent with values and priorities or if they will stand a chance to help them meet their goals.

So how do we translate these statements into an actionable plan of care upon which the patient and physician can agree? Step 2 represents the "currency exchange" between patient values/goals into a plan of treatment. They propose five general categories of treatment philosophies of "everything" (one example: "everything that has a reasonable chance of prolonging life, but not if it would increase the patient's suffering"). Based on Step 1, the physican can confirm that the patient agrees with the general philosophy. Once this is done, then the physician can decide which parts of the treatment plan are consistent with the philosophy and propose a strategy to the patient.

Step 4 of supporting emotional responses shouldn't really be a "step" but an infiltrative component that is vital to ensuring that the patient feels well supported (and probably improves the likelihood of success/agreement on the plan, but if agreement isn't reached, proceed to Step 5).

Step 6 describes a "harm-reduction strategy" for responding to requests for burdensome treatments that are unlikely to work (in the context of a "patient philosophy" of vitalism). Repeated badgering of the patient/family to reconsider DNR is discouraged in favor of keeping the patient a full code and considering a short code (but not a slow code).

The article is a quick read and it's an instant "teaching file" classic. Here are some questions to serve as discussion points (ie I want comments):

  1. In the first few paragraphs, it's inferred that a patient request to "do everything" should prompt the physician to initiate the six step process (in addition to providing the patient adequate information about their illness and prognosis). Do you use techniques to avoid the "do everything" request altogether? If so, what are they?
  2. How do you think patients respond to physician statements regarding treatment philosophies (see Table 1)? How stable do you think these philosophies are?
  3. What do you think of the harm-reduction strategy? How does it fit into your hospital's futility policy (if your hospital has one)? Is a "short code" more ethically appropriate than a "slow code"?
If you liked this article, then you'll love "Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope," by Back, Arnold, and James Tulsky (which should be mandatory reading for all clinicians in palliative care and is great for other clinicians as well).