When to use a new technology and when to die with dignity

American medicine overuses its technologies and innovation triumphs and way underutilizes old fashioned compassion, discussion and good common sense.

Over the past twelve weeks I have given weekly updates of medical megatrends in the fields of genomics, stem cells, transplantation and vaccines. These advances are the representation of innovations and entrepreneurship in biological, computer and engineering science. They are exciting advances and offer promise of hope for many patients with acute and especially chronic illnesses. It should be clear that I am an unabashed supporter of medical innovation and in the coming weeks I will add posts on advances in medical devices, imaging, the OR and more.

But perhaps it is time to “take a breather” and consider the implications of these advances. One unanticipated and actually unfortunate consequence of medical advances is the belief by provider and patient alike that all disease can be ultimately conquered – that cures can and will be found with enough time and energy. Perhaps this is true but more than likely disease will always be with us. [There is an excellent article on this topic by Daniel Callahan and Sherwin Nuland in the New Republic may 19, 2011.] Given our aging population it is important to remember that “old parts wear out.” And with our penchant for adverse behaviors such as overeating (a non nutritious diet,) sedentary lifestyle, chronic stress and (20% of us) smoking it should be no surprise that we will see epidemics of chronic illnesses such as heart failure, cancer and diabetes along many others. These are chronic illnesses that remain with us for life, are difficult to manage and are inherently expensive to treat.

So we “cause” our own illnesses and then expect medicine to rescue us with a cure. We remain optimistic that, with enough resources placed into research, the disease will be conquered. And in the meantime, doctors and patients alike expect that our current innovations and technologies will improve our lot. We in medicine, with the urging of our patients, look to deny death – at least for now. We have a new drug for cancer that will add a few moths of life but with major side effects while bankrupting the family. We have a new medical device for heart failure that will cheat death for awhile but with limited quality of life.

But sometimes it might be more appropriate to step back and appreciate that the next treatment or diagnostic procedure may offer little of value but cost a lot. We know death is inevitable; just not now, please. Sometimes it is simply more appropriate to accept the inevitability of death.

But this will require a culture change by physician and patients and their families. It will mean physicians having honest, direct conversations with patients. Patients will need to understand the real pros and cons of a surgical procedure, that new drug or the latest medical device. And then, should the patient opt for palliative care,  it will mean that the physician does not turn away from the patient but enters a new, rather profound relationship where quality of life is more important than length of life. It is where both patient and physician accept death with dignity – each growing further from the experience.

I am in no way suggesting rationing or “death panels” nor am I suggesting some form of central bureaucracy limiting choice. But I am suggesting that all of us need to “take a breather” and not be so enamored of our innovative technologies that they become used inappropriately or in excess. Perhaps it would be better said to suggest that patient and doctor together need to embrace the need for openness, transparency and honestly with full discussions of the nature and natural course of a disease and the realistic expectations of embarking on a particular course of treatment. Often the use of one or more new technologies will be the appropriate course of action. But sometimes the correct course will be one marked by comfort measures and the maximization of the quality of life.

This should be one of the new “medical megatrends” – a cultural shift of great importance in medicine and with it improved care of those with chronic illness. I would welcome others’ thoughts on this important issue.

When to use a new technology and when to die with dignityStephen C. Schimpff is an internist, professor of medicine and public policy, and former CEO of the University of Maryland Medical Center.  He is the author of The Future of Medicine — Megatrends in Healthcare and blogs at Medical Megatrends and the Future of Medicine.

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  • http://www.facebook.com/people/Ardella-Eagle/840440226 Ardella Eagle

    Bravo! 

    [b]“But this will require a culture change by physician and patients and their families.”–[/b]

    For far too long in this country have we idolized youth and ‘fast-living’.  Yes, this country definitely needs a cultural change in which a PERSON’S CHOICE is respected and not the INDUSTRY’S SUGGESTION.  I don’t foresee such a radical shift in the media’s persuasion, however, it’s good to see that this issue is being recognized as a problem.

    [b]“I am in no way suggesting rationing or “death panels” nor am I suggesting some form of central bureaucracy limiting choice.”–[/b]

    Good gracious, no!  However, the choice to ‘do nothing’ is very often overlooked, sometimes not even suggested.  Sometimes, consequences are not explained properly because the new treatment is still in trials and not all the statistics have been compiled.

    Hear, hear for better, more truthful, communications between provider and patient!

  • http://twitter.com/TheUnorthodoc Doc Cory

    Thank you, Dr. Schimpff, for the much needed reminder. Medical science is what it is because the personality of doctors historically has been to try to do all we can *for* our patients. Once, that meant keeping vigil at their bedside as there was nothing else. With all that’s available now, we often confuse this desire with doing all we can *to* our patients. It is so much easier emotionally to hold out hope and tell people things you think they want to hear. It’s far more difficult to admit that there are both places we cannot go, and further, places we should not go. Asking our patients what they want to accomplish, how they want to feel, and when they want to stop means admitting there are limits to everything. It is, however, the ultimate example of respecting our patients’ time.

    Cory Annis, MD

  • Anonymous

    Yes you are absolulely right patients must be treated with dignity and respect, especially at end of life.After all we only have one chance at it and when its done badly its never forgotten by the family. But what has happened to Quality care, time when patients could speak to a health care professional and they  had time to listen to their worries and concerns,and they were in a position to  respond in minutes when they developed symptoms of pain or distress. Because what is happening now in reality is disgraceful, and its breaking my heart

  • http://www.facebook.com/people/Douglas-Cooper/100000437594208 Douglas Cooper

    I truley believe that without true Tort reform, the “mis-use” of our technology will continue.  The viscous circle of Doctors being pressured to churn out X number of patients, thereby not having the time to properly educate families, thereby families being every suspect of the medical personnel, thereby causing Doctors to take the path of least resistance,, thereby intubating the same  pt again with severe COPD, smoking, and the family saying “you have to do something,  Doctors aren’t trained to put on the brakes, nor are they generally inclined to and really I can’t blame them.

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