God, Doctor, and Patient: The Uncomfortable Hospital Triad

I would never pray with a patient at the bedside. What doctor has time to talk about God? And who knows whether a patient will find the suggestion of prayer offensive, helpful, or rapport-building? Most of us doctors, when we think about prayer at all, keep it as far from our work as possible. I am an observant Jew, yarmulke wearing and Sabbath observing, and I pray three times a day. But never would I mention to my colleagues a word about my daily spiritual practice. We are practitioners of our own esoteric art, which we like to pretend is uncontaminated by outside influence, and our white coats are not cassocks. Even when an appreciation of religion might be of some use, we make an extra effort to keep it at a distance. When patients are about to die, or when our care is serving only to prolong suffering, we delegate the hard questions to highly trained ethicists sharing our worldview. When there's nothing left but to commend a patient's soul to its maker, we murmur something about "medical futility."

Thus the small but growing scientific literature linking prayer to health is discussed by nobody in my circles. It's in the same category as "alternative" medicine (acupuncture, Chinese therapies, ayurvedic medicine, and the like) or, for that matter, most of psychology - areas worth dabbling in but never imagined by orthodox practitioners as primary to the profession. Once organic causes have been thoroughly "worked up" (through appropriate technologies and laboratory tests), then we are free to speculate about the psychological and spiritual realms, usually with a cocked eyebrow or an eye on the clock.

What would it mean for prayer to help the sick? It's a question linked to others great philosophers have plumbed and foundered on: the existence of evil, God's relationship to prayer, the necessity of any belief in God at all when one prays. One might think that the scientific literature shouldn't find the problem as difficult as the philosophers - just find an objective measure of "prayer" and "help." But objective measures of prayer are precisely what are lacking, as psychologists Kevin Masters and Glen Spielmans explained in a review published in the Journal of Behavioral Medicine in 2007: what the field needs are "experimental studies based on conceptual models that include precise operationally defined constructs [and] longitudinal investigations with proper measure of control variables." In other words, we're back to the same issues: what is prayer? And how do we tell what is the effect of prayer, and not merely the nonspecific warmth of human companionship?

God is most relevant to me at work for different reasons. I'm a medical resident in his final year whose routine usually involves others' tragedy. Religion in my practice is usually evident only as a wedge between what I want and what patients - and, more often, patients' families - want. Enveloped by a medical culture which is difficult to step outside, I often catch myself assuming with an unquestioning certainty exactly what should happen in a given case: this person over here is worth treating (from a "medical" perspective - that is, from the perspective of my guild), there is progress to be made here, and we should try to convince the patient and family of this; or, conversely, there is "nothing to treat here," and any protestations to the contrary are due to delusion, illusion, or "cultural differences," a common euphemism which includes religion. Often it happens that religious patients and their families want more care than we doctors want. This is frustrating for me as a religious person: what's the point of all the spiritualism if it only blocks lines of communication between doctor and patient?

As in the case of prayer and health, the issue of end-of-life care for religious patients (and their families) can be illuminated through empirical research where otherwise we might get lost in philosophical byways. In a recent issue of the Journal of the American Medical Association, Holly Prigerson at the Harvard Medical School Center for Palliative Care, together with her colleagues, published a rigorous study of patients who use religious faith to cope with a diagnosis of advanced cancer. Even after controlling for other variables, these patients with "positive religious coping" request and receive more intensive life-prolonging care at the end of life.

In an on-line interview, the authors declined to make recommendations to clinicians based on this conclusion. In the article, however, they observe "because aggressive end-of-life cancer care has been associated with poor quality of death and caregiver bereavement adjustment, intensive end-of-life care might represent a negative outcome for religious copers." This would certainlly justify doctors' bewilderment when dealing with religiously intransigent families. Such families are arguing their loved ones into more days in the ICU and a death entangled in wires and tubes.
Thinking it about it in another way, though - trying as hard as I can to think like the spiritual person I occasionally manage to be outside of work - a scrabbling after every scrap of life, even as it seems to slip inexorably away, is a perfectly religious path. For many religious people, sick or well, the question is not "Does prayer help?" but "How can I manage to pray?" Prayer has no point; its existence is enough. Similarly, I would not be surprised if many religious families viewed the question of "negative outcomes" as just another barrier thrown up to the achievement of transcendence. Life is life. Clinging on to it has no point; the clinging is enough. These days our art of medicine is always accompanied by debates about the evidence, what it is and how one introduces it into practice. While God and God's adherents frustrate me no end while I am trying to get work done in the hospital, I am vivified by those whose attachment to life is circumscribed by something other than evidence.

“The oddity of physicians’ insistence that patients follow doctors’ orders”

By the fourth sentence of the preface to The Silent World of Doctor and Patient, Jay Katz has quietly issued a startling challenge to a fundamental principle of the doctor-patient relationship. He writes:

It took time before I appreciated fully the oddity of physicians’ insistence that patients follow doctors’ orders. During my socialization as a physician I had been taught to accept the idea of doctors’ Aesculapian authority over patients. When I began to doubt this authority, that was the moment when the book began to take shape in my mind.

“The oddity of physicians’ insistence that patients follow doctors’ orders” – the phrase brings you to an abrupt halt. Jay Katz, who wrote those words in his landmark book published nearly a quarter of a century ago, died in late November at the age of 86.

--Michael Millenson at the Health Affairs Blog. Times obituary of Jay Katz here.

The futile slow code

I was involved in a slow code recently. (I won't say where, or when, or with whom.) They are slippery and repugnant. Rarely can any of the parties involved say with satisfaction or complete clarity when, or by whom, the slow code was suggested or agreed to. It is a substitute for an honest discussion of options with the patient and family, and it is a legal minefield.

Remind me not to get involved in them again ... when I have a choice in the matter.

The Thirty-six Million Dollar Rectal Exam

In 2004, while working at a construction site, Brian Persaud was hit in the head by a large wooden plank, lost consciousness, and was taken to the emergency room at New York Presbyterian Hospital. There he received what he says was an unjustified digital rectal exam. Persaud brought suit against the hospital, and soon, four years later, the case will come to trial in the New York State Supreme Court. The arguments in the case are legal, but the underlying issues are also medical and ethical.

More at Clinical Correlations, the NYU Internal Medicine blog. (Thanks to D.M. Esq. for a quick legal education.)

Competent to judge: Adventures in hospital ethics

The guy with newly discovered metastatic cancer who was just told of his diagnosis - when he wanted to up and leave, that wasn't crazy of him. Nor was it necessary to call a psychiatrist to judge whether the patient was competent to leave against medical advice. Is there anything magic about psychiatrists which makes them able to judge competence? Some people like titles, and other people like subspecialties. Psychiatrists on call in the hospital become surrogate ethicists, for a reason I don't understand. Because psychiatrists are on call and ethicists are not? Or because we (doctors and everybody else) tend to confuse the legal with the ethical - and we're familiar with psychiatric judgments of mental illness?

It would be too easy - unfair, really - to say that some doctors who think patients are incompetent, or crazy, are unable to see why anyone might disagree with them. But I'll say it anyway.

The Resuscitational Imperative, II

On the other hand, there is now definitely a culture (measured by off-hand comments by residents, facial expressions assumed when discussing families who do not make the "correct" decisions, and the like) which promotes the DNR order. It is taken by some as the very goal of goal-of-care discussions. If a patient is very sick, has been so for a long time, and the prospects for recovery of functional status (meaning a significant quality of life) are minimal, we are pleased when a DNR/DNI order is obtained, and even more pleased when comfort care is decided upon.

But I also want to talk to the patients fully and frankly about what "significant quality of life" means. If the patient (or her family) wants to be kept on a ventilator indefinitely, even if there is no chance of life off the machine, that would be valid - because medical futility, like all medical decision-making, involves ethical assumptions which patients and families might not share; and because health-care costs and resultant rationing, so often in the back or front of our minds when discussing such issues, are not significantly affected by long-term ventilator support. (See this brief article in the New England Journal for a discussion of both these issues.)

My goal this rotation, when I admit patients overnight at Bellevue, is to include as part of the problem list the category Goals of Care and to discuss these with the patient. This won't happen for everybody, and maybe for nobody (it gets busy). But it's something to work towards.

Meaningless directions

If you have occasion to compose or think about your living will (and I hope you will soon), please do not include the phrase "heroic measures," which means nothing at all - or, rather, many different things to different people. One person's heroism is another's medical routine. If you would rather not be resuscitated (i.e. have your chest forcibly compressed and undergo electric shock), then say so. If you would rather not have a tube down your throat to aid in breathing, say that. If you would rather people not do "too much," decide what that means to you, and write that down - and tell the person you would like to make health care decisions for you if you cannot. Don't count on people understanding what you write unless you are painfully detailed and inescapably clear.

Informed consent
Notes for a talk

Mr. C. is a 55-year-old Spanish speaking man with abdominal pain that has migrated from the epigastrium to the right lower quadrant of the abdomen. You are asked to “consent” him for a CT scan of the abdomen. Your Spanish is good enough to talk to him, but Mr. C. does not ask any questions, even when you repeatedly press him on the matter. He keeps saying, “Whatever you say, doctor.”

More here.

Death and its complications

Jewish Ethics and the Care of End-of-Life Patients. Edited by Peter Joel Hurwitz, Jacques Picard, and Avraham Steinberg. KTAV Publishing House, Inc., in association with The Institute for Jewish Studies, University of Basel, Switzerland.

End-of-life decision making is now often left to specialists. This book presents their deliberations in a way meant to be accessible to the layperson. It is a dissection, perhaps over-specific, of general questions that many of us will face when we and our families get old and sick: when is the right time to die? What are the right criteria, and who decides?

Orthodoxy finds in the classic texts, Talmudic passages as well as later decisors, not just guiding principles but specific legislation, with one overarching conclusion: that every moment of life is to be actively preserved, even at the price of decreased quality of life. Every end-of-life decision is to be met with the same standards, and nearly every deliberation can find its relevant source in the classical texts. If the circumstances of terminal illness are different today, and death can be drawn out over long weeks of desperation and indecision, this should not divert our gaze but focus it even more intently on the principles that matter. On the other hand, Reform thinkers have pointed out for years that such texts are open to multiple interpretations – generalizations are risky, and every case should be considered according to its unique circumstances.

This book, in short, presents a canonical spectrum with familiar opposite ends: the Orthodox insistence on the eternal relevance of Talmudic passages (even to vastly changed modern circumstances) whose interpretation can change only glacially, and the classical Reform deconstructive approach to Jewish law.

A second question has to do with the many treatments which are given to (or foisted upon) the terminally ill. When the time comes to die, when there is nothing more to be done (or when what is being done is clearly inhumane or futile), how can we decide what to turn off? How can we stop impeding death without actively causing it – or is there a difference? In this book, the bioethicist Vardit Ravitsky considers Israel's new law concerning the terminally ill, which has something important to say about these matters.

The best-known element of this law is a technological compromise. Some explanation is in order. Many thinkers recognize a distinction between the hastening of death in the living patient (forbidden) and the removal of impediments to the death of a terminally ill patient (required). In other words, life must be maintained -- but death, once unavoidable, cannot be artificially kept at bay. This distinction, important in traditional Jewish law, is sometimes so unclear as to appear a contradiction.

These terms have been connected to a corresponding pair in secular bioethics: withholding treatment versus withdrawing treatment that has already been given. The claim is made that withdrawing treatment, once given, corresponds to "hastening death," while withholding treatment, in terminal illness, is just refusing to place an impediment in the path of a dying patient.

Here enters the technological compromise: a timer connected to a respirator. The timer converts a treatment continuous in time (and thus one impossible to stop without "withdrawing") into a "discrete" sequence of decisions whether to continue the use of the device -- that is, whether to "withhold" or not.

Ravitsky's analysis helps us understand why such a halachic-technological compromise is necessary. If the distinction between "withdrawing" and "withholding" were of ethical import, the timer -- designed to circumvent it -- would be an instance of deception. However, Ravitsky agrees with the position of the current Western bioethical literature, that this distinction is erroneous. There is no real difference between withholding and withdrawing. Therefore, "timers may be perceived as devices that enable individuals to overcome an emotional difficulty in order to do what is ethically right. They thus become an appropriate and clever way to bridge the gap between the desired moral outcome (death with dignity and respect for individual autonomy) and a cultural atmosphere (grounded in religious tradition and ingrained values) that does not allow renunciation of the distinction."

That is, Israel is confronting, albeit on a larger, public-policy scale, exactly what American Jews confront - a conflict between moral outcome and religious tradition. The editors have performed a valuable service in collecting thoughtful essays discussing this conflict from various points of view. It's another question whether laypeople -- who don't like to discuss death -- will pick up this book.

Do Not Reconsider, II

On the whole it's a salutary thing for all health care workers to think about their patients' wishes when it comes to resuscitation and intubation. But selection bias is a killer. What I mean is that doctors start getting curious about DNR/DNI orders when their patients get very sick. Since no one thinks to ask about these orders when the patients are relatively healthy, you could be forgiven for thinking that on occasion these orders, rather than a way in which a hospital interprets a patient's wishes, are an acceptable method of declaring medical futility. But that's a big problem - you don't want these categories to be mixed up. (And, of course, any competent doctor would I'm sure be horrified at any suggestion that this is what she's doing, since - in fact and in law - there's a lot that can be done in terms of medical treatment that has nothing to do with resuscitation or intubation.) The solution, of course, is to have everyone's DNR and DNI status stamped on their foreheads the minute they're seen by their first doctor. Not only is this not happening, I even wonder if it could. If informed consent is laughable in its practical execution, what more can one expect from DNR/DNI?

Do Not Reconsider

I signed my first DNR order today. I did not refuse, but I can't say I'm proud of it. The philosophical conumdrums that come into play are weighty enough not to talk about at length.
(And what follows, it should go without saying, is not a religious or halachic treatment.)

What confused me in this instance was that I, as one of the treating physicians, was asked to confirm that resuscitation of the patient in this case would be "medically futile."

I don't know what the phrase means. Of course, I could look it up, but it seems to me on first glance -- and what is a blog after all but a displaycase for first glances and uninformed impressions? -- that most possible understandings would be either truisms or impossibilities. Does medically futile mean that resuscitation would not return a patient to his baseline functioning (i.e. before the illness)? Or that it would not cure the diseases which originally caused the cardiopulmonary problems in this patient?

Perhaps the most likely meaning is that it would condemn the participants - patient, family, and doctor alike - to a process which renders medical decision making futile, since all end points are the same.