Why must we always "do something" for the patient?

Sometimes, as the author learned from the tragic case of Mrs. A, doing nothing is a doctor's best option.

By Valencia S. Clay, MD

I took over the care of Mrs. A from my partner in December 1998, at the beginning of the holiday season. It was a routine admission for exacerbation of COPD. The chart described an 85-year-old woman on home oxygen who, according to her daughter, still sneaked a cigarette at times.

She was a kind, shy, soft-spoken woman. Surrounded by the white sheets and blanket of her hospital bed, she seemed incredibly tiny. She reminded me of my grandmother. She always smiled, even when she complained of her usual dyspnea on exertion. I had to drag this or any other complaint out of her because she "didn't want to bother the nurses."

Mrs. A's hospital course was progressing uneventfully until she began complaining of gas. The usual treatment of antacids and H₂ blockers failed, as did several attempts to persuade her to talk about her pain. Gradually, the fuzzy negative of her clinical condition developed into a clear picture of unstable angina. The cardiology department started medical management and ordered a persantine thallium scan, which was abnormal. All the while she smiled, and we had to beg her to call the nurse if the chest pain recurred. When medical management provided no relief, cardiology decided to perform a cardiac catheterization.

I was worried about the risks of catheterization in someone of her age and fragile health. I was also pondering what we would do if we found extensive blockage; she was in no shape for coronary bypass surgery. I strongly believed that we would find a problem we would not be able to correct. Why perform a procedure if you'll be unable to do anything with the results? Is it ethical to perform a procedure with considerable risk, and little chance of gleaning useful information, just because we have the technology? Every test and every treatment is not for every patient.

The true art of medicine today, I believe, is to know when to just say No. Most physicians have not yet mastered this art, and neither had I. But because there was a very small chance that we'd find a lesion that could be treated with angioplasty, Mrs. A underwent cardiac catheterization.

For once, I hated being right. The cath results showed 99 percent stenosis in the left main coronary artery and 95 percent in the right. This dear, sweet lady was hanging on by a thin thread of red blood cells tumbling in single file through coronary arteries with lumens the size of capillaries. At any moment she could choke off the last of her left main and succumb.

The cardiologist, of course, recommended bypass surgery. So now we were backed into a corner; one dangerous procedure had led to an even more dangerous treatment. While I was trying to absorb and process this information, Mrs. A's nurse called to say that the arm used in the catheterization was now cold and blue! Blessedly, she underwent repair of the blocked vessel in her arm without complication. Would the blocked vessels in her heart be as cooperative? Would her heart be as forgiving?

We consulted the cardiovascular surgeons, who immediately asked the pulmonary specialists to "tune up" the patient's lungs. There is only so much "tuning" that can be done to 85-year-old lungs damaged by 70 or more years of smoking. The surgeons seemed reluctant at best, and the pulmonary experts noted her poor prognosis in the chart.

Mrs. A was not told, however, that her prognosis was poor whether or not she had the surgery. She was given the impression that she had no choice, that she had to have the surgery or die. She was not given the opportunity to say No. As her advocate, I had to give her the whole story. I had to tell her that she was, as my grandmother used to say, "trading the devil for the witch." She indeed had options, but both options seemed to lead down the same dismal path.

I spoke with the patient and her family several times, and wrote long, philosophical notes weighing the risks against the benefits. I voiced my doubt that surgery would produce any improvement in her quality of life. After all, shouldn't that always be our goal in treatment? And then I did something I should have done much earlier: I stopped talking and writing and questioning—and started listening to the patient.

She seemed even smaller now, and much weaker in her ICU bed, hooked up to the monitors and the heparin and the nitroglycerin drips and every other bell and whistle known to modern medicine. She looked scared. When I asked what she wanted to do, realizing in my own mind that she would most likely die either way, she cried. Her reaction surprised and disturbed me. I had hoped she would simply reassure me that she was all right with this situation. I had expected to see that stoic, almost pleasantly expectant resignation to impending death I have seen in so many elderly African-Americans. I expected to hear, "I'm ready to go home to be with Jesus, baby." But instead, she cried, and I cried with her.

When she settled down, Mrs. A told me that she did not want the surgery; she wanted to go home to spend Christmas with her family. I agreed with her decision. She smiled and sat up a bit straighter in bed. She didn't look quite so small any more. She leaned forward and, in a confidential whisper, told me that her grandmother had lived to be 100 years old. Then she said: "I might fool them all and live to be 100, too!" She laughed, and I laughed with her.

I spoke with the patient's family, who said they would abide by her decision. When they came to take her home, I prayed with them, we shed more tears, and I wrote her discharge orders. It was two days before Christmas.

She did surprisingly well over the next week or so, and spent the holidays with her family without further chest pain or trouble breathing. She had no complaints, but her family did. They began to question the decision to send her home and wanted a second opinion. They voiced these complaints to my partner, who had taken over her care since her discharge. He explained that he was in full agreement with the patient's decision, but they insisted on a second opinion.

Another cardiovascular surgeon was consulted; he told the family that Mrs. A had a 50-50 chance of surviving the surgery. They were advised that those were not good odds, but they made the decision to go ahead with CABG anyway.

Mrs. A tolerated the surgery, was weaned off the ventilator, and went home three days post-op. We received repeated calls from family members and home health nurses about her shortness of breath and pain unrelieved by medication. I did not want to be proved right again because she would have to die for that to happen. I prayed that she would recover.

I went out of town a week after the surgery. When I returned, I learned that Mrs. A had died. Some of my colleagues had attended the funeral. And a grand funeral it had been, with an elaborately carved mahogany casket. I imagined her in it, among the white satin cushions, small and still.

Would she have lived longer if she had not had the surgery? Only God knows. I do believe that she would have lived a life with better quality had she been left alone. Must we always do something? Is any treatment better than nothing at all?

I pondered these questions that next week as I traveled back to my hometown. As it happens, my 90-year-old, reasonably healthy grandmother had just had an MI. As treatment options were discussed, her physician was just as reluctant to cath her as I had been with Mrs. A. We all agreed on medical management only. Even after the second MI and resultant congestive heart failure a week later, we stuck with medical management. Grandmother, like Mrs. A, intuitively knew what was best for her. She refused surgery.

I also refused a more aggressive approach because I was afraid of what we would find, of what we would do, of doing everything and losing everything. It was the most difficult decision of my career. My heart screamed, "Do everything to save her," but my mind saw Mrs. A, small and scared in her hospital bed, still smaller and suffering in her bed at home, and finally small and still in her satin-lined mahogany eternal bed. My grandmother was my world, and as hard as it was to refrain from acting, I could not do anything that would possibly harm her. I could not gamble her away on, at best, a 50-50 chance. So we waited and prayed.

As I write this, it is now December 1999, and the holiday season is upon us once more. It is a time of beginnings and endings, of joy and pain, of thankfulness and regrets. As I look back over the year, I am thankful for many things in life, and regret some things that I did not do. But there is one thing I do not regret: my decision, as difficult as it was, to treat my grandmother with benign neglect. If she were here with me, she would agree that this decision was best for all concerned. But she is not here; she is at home preparing to spend the holidays surrounded by her loving and grateful family! We truly believe she is alive and well today because of what we did not do. For that blessing, we offer our humble thanks.

The author, an internist, is assistant professor of clinical medicine at Morehouse School of Medicine, Atlanta.

Valencia Clay. Why must we always "do something" for the patient?.

Medical Economics

2000;6:145.