How to treat patients who want everything

The Annals of Internal Medicine had 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.

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:

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? 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”?

Lyle Fettig is a palliative care physician who blogs at Pallimed.

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  • Medical Resident

    One of the first steps in addressing the “do everything” policy is to explain to patients that everything we do in medicine has risks and benefits. The physical actions which are required to enact the “do everything” policy implies that we are accomplishing something, that we are actively caring for and possibly curing patients, and that we are practicing good medicine. This is not always the case – we may be harming them or, at the very least, providing only minimal benefit. Just because we can offer laboratory tests, imaging studies, and invasive procedures (these will never be in short supply in the American medical system), it should not always be inferred that these active approaches to medical care are superior to less active approaches or are better for the patient.

    Patients and their families respond in a variety of ways to physicians’ philosophies about treatment – their responses vary depending on many things, including (1) the patient’s and family’s understanding of illness and prognosis (2) their readiness to accept the prognosis (3) family dynamics which often play an instrumental role in the decision-making process and (4) the overall sense of hope which remains, in spite of all the hard evidence or treatment philosophies which are presented to them.

    These are just some initial thoughts – a piece that I wrote on comfort measures addresses some of these questions in greater detail, But without a doubt these are not easy questions, and there are no easy answers. We must be willing as physicians to spend time with families and to provide them with the best information we can so that they can make the best decisions for their loved ones and themselves.

  • Dr. Pi

    I recently along, with my attorney sister, tried to talk my frail, 90-year old, 83# mother out of a DNR order when she !. Stopped getting out of bed , stopped, eating and drinking and then (of course) developed renal failure. EXTENSIVE talks with EVERYONE fails to persuade her to accept the end of her long active (until the previous 6 months) life. Sometimes the patient’s magical belief in Modern Medicine is unshakeable. Fortunately she had signed a Medical power of attorney to me, her MD daughter, and so after the
    requested FULL resusitation surprising worked to restore her heart rate, but not her conciousness, I halted this futile, inhumane exercise after 15 hours in the ICU. My attorney sister was appalled at how mom appeared those last few hours, but told me, “The level of competency to self-determine one’s level of resusitative efforts is set very low and her renal acidosis does not make her incompetent in the eyes of the law.” It was undignified, and not (in my mind) helpful, and affected my non-medically trained family members deeply to see what misplaced faith in Medical Miracles has wrought. Even I, as an ED physician, who had seen far too many similar situations, could not persuade my mother to forgo the violence of resusitation. Like my sister said, “There are NO long-term goals for this patient.” It was a very painful process for those of us left behind to process, and not without some anger towards our mother, who while instilling in us as children the dignity, necessity of maintaining a humble quality of life, and always expressing kindness towards others, left us with a bitter memory of her last few hours, which seemed so at odds with those values she had instilled in us as children.
    A useful article, but alas, so difficult in the real world.

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