Correspondence

Clinical Problem-Solving: When Too Much is Too Little

N Engl J Med 1997; 336:1458-1459May 15, 1997

Article

To the Editor:

The Clinical Problem-Solving article “When Too Much Is Too Little” by Morrison et al. (Dec. 5 issue)1 should be required reading for every physician who cares for dying patients — and for every physician in training. It is a sobering account of how far we still have to go in respecting the rights of patients and their families to reject aggressive therapy. It also makes it clear that death is not always the enemy of the patient and that for some patients the least traumatic death is a legitimate goal of compassionate medicine and by no means always a professional or personal failure on the part of the physicians.

Equally disturbing is the article's pointed reminder that physicians need more deliberate training in the care of the dying, more knowledge of and training in palliative care, and a more precise understanding of the distinctions between withholding or withdrawing life-sustaining therapy and euthanasia or physician-assisted suicide. Perhaps most disturbing of all is the fact that there was no physician to coordinate the care of this patient and apparently no attempt by the physicians to reach agreement with the patient and his family about the goals of therapy.

If this were an isolated case, it would still be an indictment of the hospital where it happened. But the sad fact is that there are many similar cases that reveal the same problem: lack of coordinated care; unwillingness to honor a legitimate choice by the patient, particularly if it involves the rejection of life-sustaining treatment; problems with the open discussion of the medically indicated possibilities for end-of-life care; hesitation to refer dying patients to hospice care; confusion between euthanasia and physician-assisted suicide, on the one hand, and allowing a person to die by withholding therapy, including food and water, on the other; lack of adequate knowledge concerning pain control and palliative care; the subtle but powerful notion that the death of a patient is a professional failure; and the equally powerful imperative to use whatever technology is available to sustain life (which, in many cases, amounts to a prolongation of death). I would indeed call this a case of cruel and unusual punishment, if it were in fact unusual.

Perhaps public awareness of such cases has something to do with the current demand for physician-assisted suicide. Indeed, if the alternatives were only the treatment in this case and the assistance of a physician in the patient's suicide, it would be difficult to oppose the latter. Physician-assisted suicide might be viewed by some as a quick fix for the failures — medical, ethical, and legal — in this case. And the current rush toward cost containment through managed care might increase the public pressure for physician-assisted dying. Such cases tend to underscore the primordial human fear of abandonment, but in the current climate, what is at stake is not so much abandonment by medical professionals as abandonment to technological medicine.

When will we learn that “too much” can be a fate worse than death? And that reform in the medical profession itself — not the intrusion of law into medicine — offers the best hope that the problems exemplified by this case can be substantially eliminated?

W.D. White, Ph.D.
University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7240

1 References

1. 1

   Morrison RS, Meier DE, Cassel CK. When too much is too little.N Engl J Med 1996;335:1755-9.
   

To the Editor:

The article by Morrison et al. paints a grim picture of granting a patient his dying wish.

It was of note to some of us who monitor and review home health services that the patient was discharged on the 21st hospital day with 24-hour home health care. It is our consensus that this may have been unwarranted. As noted during his hospital stay, he was “cognitively intact,” with “generalized left-sided weakness.” Psychiatric evaluation revealed he wanted to go home and was able to make an informed decision.

On the basis of these few comments on the patient's actual functional status, 24-hour home health care seems excessive, despite the patient's grave prognosis. Around-the-clock home care services are usually reserved for patients who cannot be safely left alone and who need total assistance with tasks that might be required at night, like diaper changes, hands-on help with transfers to and from the toilet, or turning and repositioning in bed.

How was the decision reached? What were the patient's nighttime needs? Did he need help with using the toilet or moving about? If not, perhaps home care during the daytime hours only would have been more appropriate.

Edward Prunier, M.D.
Anders Holmberg, M.D.
Joseph Leahy, M.D.
New York County Health Services Review Organization, New York, NY 10010

To the Editor:

We cannot help thinking, as we read the case of a patient who presents with a solitary brain metastasis from a primary non–small-cell lung cancer, that he would have benefited from a standard course of brain radiation therapy. Radiation therapy could be given even if the solitary lesion was not resected, given the patient's refusal of surgery. A standard whole-brain dose of 3000 cGy given over a period of 2 weeks causes minimal morbidity except for hair loss and gives good palliation of neurologic symptoms in approximately 50 percent of treated patients, with a median survival of 18.2 weeks.1

It is tempting to think that as well as improving his leg weakness, such therapy might have prevented or at least delayed the seizure activity the patient experienced at three months. Whole-brain radiotherapy is an example of classic palliation by irradiation, and the opportunity was lost in this case.

Sidney P. Kadish, M.D.
Shelagh E. McCauley, M.D.
St. Vincent Hospital, Worcester, MA 01604

1 References

1. 1

   Kurtz JM, Gelber R, Brady LW, Carella RJ, Cooper JS. The palliation of brain metastases in a favorable patient population: a randomized clinical trial by the Radiation Therapy Oncology Group. Int J Radiat Oncol Biol Phys 1981;7:891-895
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Author/Editor Response

The authors reply:

To the Editor: We appreciate and agree with the comments of Dr. White. Drs. Kadish and McCauley note correctly that a course of radiation therapy might have improved the quality of life for this patient. Radiation therapy was offered to this patient initially during his first hospitalization but was refused, and to our knowledge, the subject was not broached again.

Prunier et al. raise the question whether 24-hour home care services were appropriate for this dying patient on the basis of the limited information that was provided regarding his functional status. The patient was evaluated on several occasions before discharge by a physical therapist, home care coordinator, several nurses, his physicians, and a social worker, and his application for 24-hour care was approved by the state Medicaid Office. At discharge, the patient required assistance in all of his activities of daily living and could not walk, transfer from bed to chair, or use the toilet without assistance.

Inadequate home care is a substantial barrier to good care for dying patients in this country.1 The Medicare hospice benefit generally provides only 4 hours of custodial home care services per day,2 requiring families to provide or hire someone to provide the remaining 20 hours of demanding personal care that dying patients require. Many families are unable to provide this type of care or cannot afford it. That this patient was able to be discharged to his home to die with a home care attendant for an adequate number of hours under the Medicaid system is a positive aspect of this case.

R. Sean Morrison, M.D.
Diane E. Meier, M.D.
Christine K. Cassel, M.D.
Mount Sinai School of Medicine, New York, NY 10029-6574

2 References

1. 1

   Meier D, Morrison R, Cassel C. Improving palliative care. Ann Intern Med (in press).
   

2. 2

   Sachs GA, Ahronheim JC, Rhymes JA, Volicer L, Lynn J. Good care of dying patients: the alternative to physician-assisted suicide and euthanasia. J Am Geriatr Soc 1995;43:553-562
   Web of Science | Medline