Friday Reflection 62: The Ethics of Telling Patients We Have Nothing Left to Offer

TR is an 88-year-old man who is disabled and in chronic pain from spinal stenosis and knee osteoarthritis. He has multiple other medical issues, including coronary artery disease and COPD.

He has been through years of treatment for his knees and back, including physical therapy, multiple joint injections, and an in-office procedure for spinal stenosis. He has been on multiple regimens of oral pain medications. He is not interested in surgery (and probably would not be considered a reasonable candidate if he were).

He comes to a visit and asks what can be done.

We are taught never to say, “There is nothing I can do for you.” We may be out of surgical or medical options, but we can always continue to care for and support our patients. This is not part of the Hippocratic Oath, but it is so integral to our training that one might think it belongs there.

There are good reasons to caution doctors from saying some version of, “I am sorry, I don’t think there is anything more I can do for you.” It is true that in 21st-century medicine, the act of caring for patients has been so trivialized that we need to remind ourselves that caring is not just a last resort but our first responsibility.

Hope in the face of illness is exceedingly valuable. Robbing this hope is not only cruel, but probably bad for the health of patients.

Then there is the truth that when one doctor has nothing left to offer, medicine often still has more to offer. I am still haunted by at least one case when I mistook my lack of knowledge for a shortcoming in the field.

A doctor saying he has nothing left to offer may be taking the easy way out. Further research or a considered referral often suggests effective treatments, if not cures. There is always a risk that when we say, “We can’t help,” we are wrong.

All this being true, I don’t think we admit that there is nothing left to be done often enough. The Modern Hippocratic Oath does include the line:

I will not be ashamed to say “I know not”, nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

Is it that much of a stretch to imagine the oath saying:

I will not be ashamed to say “I have nothing left to offer beyond my ongoing care and commitment”, nor will I call in my colleagues, knowing they have nothing to offer beyond protecting me from admitting medicine’s limitations.

We no longer conceal bad diagnoses from patients; we consider this unethical. It is time that we consider it unethical to conceal that we have nothing to offer beyond palliation.

It is hard to tell patients that the best we can do is control pain, especially when we have been trained not to. It takes work to be sure that neither you nor your colleagues have something to offer beyond a hamster wheel of care to provide hope but nothing more. It also takes some guts; we can never be 100% sure that nobody has anything to offer.

Yet there are downsides to never saying we are done. Many patients accept that further care is futile, not after an honest conversation, but after being worn down by my endless visits, treatments, and promises that lead nowhere. All the while, time and money are wasted; time and money that could be better spent on life. The useless medical care leaves patients and their families increasingly frustrated by a medical system that refuses to be honest and caring.

There are patients who welcome an honest assessment of their options and shift their focus to living with their disease and disability. There are also patients who do not. I’ve had patients fire me for saying there was nothing to do. They left me to get on that hamster wheel of care. This decision did not make them better, but maybe it made them happier and more ready to accept the inevitable. Eventually.

TR calls now and then and comes to see me every three or four months. He tells me about his symptoms and the things he wishes he could do. I tell him there are things he could try and people he could see, but I let him know I don’t think any of these options would be productive. He tells me he’s not interested. I advise him to push up on his pain medications and to pretreat his symptoms; I know he will not take this advice. I know we will repeat this visit in the future; I actually hope we will, for years.