Betty was complaining at an escalating rate. She’d been in her nursing home for four years and wasn’t happy. She kept coming up with new symptoms like aching, fatigue, nervous stomach, tingling, dizziness, etc. Her daughter Nancy was getting daily calls from Betty and the staff at the nursing home. Multiple trips to the doctor for diagnostic tests had ensued: blood counts, liver functions, x-rays, thyroid function, plus many others. All were coming back normal. The neurologist and theumatologist had been unable to come up with anything. Betty was getting a bit forgetful but wanted to be in charge of everything – her finances, health decisions, and daily life.
Nancy didn’t know what to do. Mom was being demanding and unreasonable, wanting more medications. An antidepressant had made her sleepy and dizzy. She seemed to be sensitive to all medications yet was demanding something for symptom control, “Honey, they just aren’t doing anything for me. They’re doing nothing to help me. I’m not sleeping and am aching all over.”
Nancy and I were on a board together and she asked me to see Mom in consultation just to review things. I saw Betty in the office. She was well groomed, talkative and demanding, “Doctor, you just have to do something. I’m suffering and no one pays any attention. I think they’re all a bunch of idiots, don’t you?”
Betty though was pretty sharp. She could talk current politics, knew common dates and events, and could reason fairly well. The tests didn’t show any cancer, inflammatory illness, or metabolic problems. In other words, I couldn’t come up with anything either.
I broke the “news” to Nancy who said, “Well, can’t you just give her a placebo?” Actually, our formulary at that time (a number of years ago) carried a “drug” called Obecalp. As you might have guessed this is Placebo spelled backwards and was doled out now and then but I had never prescribed it. Nancy begged me to try it for her Mom, “It can’t do any harm, why not? I know doctors don’t want to deceive patients, but I’m desperate and so’s Mom!”
With more than a little reluctance, Betty was given Obecalp for her plethora of symptoms. A few weeks later I got a call from Nancy, “Your’re not going to believe this. Mom loves her Obecalp. All is well.”
It seems like a combination of laying on of hands, belief, a daughter’s love, and the placebo effect all played a part in making Mom comfortable. She died in her sleep a few years later.
Comment: The word placebo comes from Latin meaning “I shall please.” The placebo effect is real although not well understood. It exemplifies the mysteries surrounding the mind-body connection. Why does it work about a third of the time for real pain? This type of effect points out why it’s important to use placebo controls in medication trials where both the patient and researcher are kept “blinded” as to which subjects are using the study medication or the placebo control.
Today, with more modern transparency and autonomy, it would not be considered ethical to prescribe a placebo for a patient. Do you agree doctors should never do this? According to a study reported by the Wall Street Journal a 2008 survey of nearly 700 internists and rheumatologists published in the British Medical Journal, about half said they prescribe placebos on a regular basis. Do we still often prescribe just to provide hope as the patient leaves the office with something in hand other than reassurance? Actually, many supplements, diets, cold remedies, cough medications and antibiotics are often given without convincing evidence proving that they are useful or necessary at all. The patient walks out of the office with a prescription which may be more harmful than a placebo, which at least doesn’t have potential harmful side effects.
Recently Harvard created an institute dedicated wholly to the study of placebos, the Program in Placebo Studies and the Therapeutic Encounter. One of the issues they will study is whether placebos should return to be part of standard medical practice.
It was Sir William Osler, one of the founding fathers of modern medicine who said, “The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.”
Jim deMaine is a pulmonary physician who blogs at End of Life – thoughts from an MD.
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