How bad patient outcomes affect physicians

Ms. FR didn’t look so great even when I first met her. She had been admitted to the hospital three times in past 6 weeks for nausea/vomiting and generalized malaise. While the cause of her acute illness was not entirely clear, we suspected that her widely metastatic breast cancer had something to do with it.

By the time I met her she had already been in the hospital for 1 week. She was admitted for nausea/vomiting leading to dehydration so severe that her kidneys were failing. Her doctors appropriately started her on aggressive IV fluids, which brought her kidneys back, but also exacerbated her long-standing heart failure. After getting her heart failure under control, and with her kidneys back to normal, her doctors transferred her to my service with the plan that we would administer her first dose of chemotherapy.

She didn’t look entirely ready to receive a highly toxic chemotherapy agent. She had a blunted expression, fatigued easily, and needed help just to get around the room. Still chemotherapy was the only real shot she had of getting a better handle on a disease that even with our best efforts would eventually take her life. So we pushed forward and administered the chemo.

At first, things were going fine. She experienced some minor nausea with the medication but otherwise looked the same. The next day, however, her urine output started to drop and her kidneys showed signs of failure. Thinking that she was getting dehydrated again, we gave her fluids through the IV. But her urine output continued to drop and now too her mental status. Whereas before she would carry on a conversation, she became disoriented to place and time. Then her liver started to fail. She was deteriorating quickly, and I had little clue as to why. Was she dehydrated, was she in heart failure, was she infected?

I went home late that night never having left my work. I ran the differential diagnosis in my head over and over, thinking of what else we could be missing. I got home and spent an hour on the phone with the overnight team relaying my ideas and getting updates on her clinical status, while I watched her vital signs from my laptop. Fearing the worst, I called her son. I told him what I knew and assured him we were doing our best. The next day she began to perk up. Her kidneys began to improve as did her liver. She was more awake, though still confused.

However, the following day, we had a new problem on our hands. Her bone marrow was failing and all three of her blood cell lines were down. Again, we racked our brains, running differentials, ordering tests, worrying, waiting, trying different things . . .

Doctors go into medicine to help people. Death of course is inevitable — we know that — but illness isn’t. We are almost by definition optimists. We believe in our craft. We expect patients to get better with our treatments, and we are shaken up by those that don’t.

There are different types of bad outcomes, however, each of which has a different impact on us. There are patients who get to hospital already on a downward spiral — the elderly patient with already bad lungs who develops a multidrug resistant pneumonia and dies in the ICU two days later of septic shock. There are patients who are sick and can’t be helped — the woman I admitted two weeks ago for nausea/dehydration secondary to a small bowel obstruction from metastatic cancer. There were no more chemotherapy options for her and so we turned our efforts towards palliation and comfort. Then there are patients who we think we can help but despite our efforts don’t get much better; these are also difficult cases.

One week ago I admitted a woman with metastatic lung cancer for an asthma exacerbation. She became short of breath at home after moving around some old boxes. I thought the dust from the boxes triggered a simple asthma exacerbation, which we would turn around for her in a matter of days. However, despite aggressive measures, her breathing isn’t much improved, and we now think most of her airway disease is from the cancer and will not be readily reversible.

All of these cases weigh on us as physicians, but none are as difficult to contend with as cases such as Ms. FR’s. Most patients that don’t do well come to us on a downward trajectory. We try our best to change the course of their illness and fail. While we are distraught by these cases, we find solace in telling ourselves that if we had gotten to them earlier things may have turned out differently.

Less frequently, our patients develop a negative trajectory in front of our very eyes. Ms. FR came to me with functioning kidneys, liver, and bone marrow and under my care got worse. For a group of people intent of helping others, cases like these go against our very grain and challenge our worth as doctors and individuals. Some of my colleagues would argue that I’m being too hard on myself and oversimplifying the issues. Patients that do poorly under our care rarely due so because of any error or deficiency on our part.

At the same time, Ms. FR was not a healthy patient by any means. She had widely metastatic breast cancer. Even though her organs were not failing when I met her, the potential to get worse, and to get worse quickly, was always there because of her underlying disease.

After a few days, Ms. FR got better. Her kidneys, liver and bone marrow recovered completely. Most of her acute illness, it seems, was from the chemotherapy, and once the medication cleared her system she steadily improved. In fact, she left the hospital more energetic than when I first met her. Furthermore, the complications she had in the hospital were not preventable nor any fault of my own. There was no way of knowing how she would respond to the chemotherapy. In the end, medicine is a risky business.

Nothing we do is without harm. Every decision is a balance between risks and benefits. We all know this. But for those of us in the middle – those intimately involved with presenting, weighing and making those decisions — knowing that fact seldom makes it any easier.

Shantanu Nundy is an internal medicine physician who blogs at BeyondApples.org.

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