When Best Intentions Go Wrong--First, Do No Harm

Richard S. Leff, MD, FACP
Aug 07, 2012 3:45 PM
When a patient with chronic paraplegia is admitted to a hospital due to a severely infected wound, he is shocked to be offered the option of comfort care by the admitting hospitalist. Although this palliative choice was undoubtedly offered with the best of humane intentions, to a previously independent adult facing a long course of expensive unreimbursed treatment with uncertain outcome, this represented denial of the value of the life he had chosen to pursue. The fact that the patient did not consider himself terminally ill underlies the unintended consequences of this discussion. This real case, which was reported in the July 2012 Hastings Center Report, raises important questions about the potential consequences when comfort care measures are inappropriately or insensitively suggested to patients with chronic progressive illnesses such as cancer. When end-of-life symptomatic care is offered in a way that does not address the patient's pre-existing understanding, it has the potential to rob patients of self-esteem. In some cases it may communicate that their life does not have value, just as the offer of comfort care did for the patient with paralysis.

In discussions with oncology colleagues in community practice it is very clear that hospitalists inexperienced in care of patients with cancer as well as other hospital team members (most notably discharge planners) often approach patients with the option for hospice-based comfort care in situations where treatment proven to have significant benefit may be available. This occurs before the patients as well as their families and oncologists might consider them “terminally” ill. While on the surface this seems harmless, it may raise questions in patients' minds about the value of their lives. This may have a profound effect on a patient’s feeling of self-worth and the quality of his remaining life, particularly in an elderly patient who may worry about the burden he places on his family. This is not to suggest that oncologists and palliative care specialists should not offer comfort care to terminally ill patients. However, sensitivity to the context of the discussion is essential. In an era of increasing pressure to control the cost of cancer care by avoiding futile and sometimes harmful therapy at the end of life, safeguards are necessary to prevent well-meaning but under-trained caregivers from prematurely or ineptly offering an alternative that could suggest to patients that they are no longer worthy of the care they have been receiving. This conversation, shifting from active treatment to comfort care, should be reserved for caregivers who have been involved in the patient’s care previously so that the change in direction is not viewed as abandonment or loss of worth. Although oncologists have been correctly criticized for delaying end-of-life care discussions with patients who would have been better served by earlier discontinuation of toxic interventions, the harm of prematurely and insensitively offering comfort care must be considered as well. Our duty to our patients goes beyond delivering the right treatment to the right patient at the right time in the right way. We can learn a great deal from the paralyzed patient’s experience and need to assume the responsibility of sharing these lessons with hospitalists, emergency department staff and discharge planners as well as other members of the cancer care team to help protect our patients from harm done inadvertently in the name of compassion.