Lifelong learning demands energy and curiosity. It also demands good hearing and eavesdropping on your colleagues as they care for patients and teach tomorrow’s doctors.
So perfect! All of these ethical questions go out the window with your individual patient’s experiences. Paternalism to one patient is a blessed escape from 1009 decisions for another. These ethics debates cannot be had in the vacuum of a classroom and hold any value.
Oct 17, 2022·edited Oct 17, 2022Liked by Adam Cifu, MD
Cifu: "A patient, dealing with illness, in a completely foreign situation, often needs assistance articulating and applying his or her values and wishes."
Nailed it. There is a meaningful distinction between informed consent ("assent" in this exchange) and paternalism. In this particular case...
1. Dr. Z knew his patient and her values; a relatively rare thing for hospital-based physicians.
2. After offering his recommendations he still queried her wishes ("Is that alright?") and was presumably willing to honor them, even if she opted for a more aggressive course of treatment.
3. He talked with her post-hospitalization since patient wishes are often impacted by ICU stays.
Thank you for sharing this case and your humility/beginner's mind.
In 1992 my hubby was diagnosed w a rare AML leukemia given less than 10% chance of living 90 days without a bone marrow transplant. We were lucky to get seven years with the wonderful team at Fred Hutch and treatment ordeal that can only astound an observer w the human body's ability to tolerate toxic assaults and survive.
The experience taught us some valuable lessons among them nearly every choice is a crap shoot. Prophylactic Rifampan w 1 in a million adverse events nearly killed him w rare allergic reaction which taught us odds matter less than individual outcomes.. We also learned antibiotic associated diarrhea is totally eliminated with some yogurt eaten a few hours after dosage to replace some healthy gut bacteria!
Shall we start gathering all of the anecdotes? There seems to be quite a lot. SADS is now one of the top ten killers of under 40, isn't it? Doesn't the CDC data show that for 2021? What? You can't find the CDC data either?
Thank you for sharing that story Dr. Cifu. I think this is something difficult to teach clinicians. I am a PA in orthopaedics and teach FP residents, PAs and NPs. Granted, ortho isn’t ‘life saving situations’, but is quality of life and learning what the patient’s expectations are. I frequently find myself more in the current shared decision making model, but patients always ask, “what would you do, if it were your knee/shoulder/hip/etc.?”. I do try to be honest and not paternalistic. This story shows you need to be able to have a bit of all of the above approaches. Thanks again!
Thank you for your article. One of the biggest miscommunications I see in our healthcare system revolves around the Do Not Resuscitate order. Patient's families think if they sign it the doctors will stop taking care of their loved ones. Doctors think everyone understands that it only means they will not perform CPR or perform extraordinary measures if a person's heart stops beating. People also don't know that you can specify which extraordinary they do not want to be taken, for example no compressions, no intubation or no feeding tube. Doctors need to slow down and explain these things. Medical facilities have begun to use palliative care doctors to help in these explanations, but I do not think the facilities themselves understand the need or when to call these specialists. The Center for Practical Bioethics has a workbook, Caring Conversations, which explains medical directives, who to choose as your medical decision maker and what the DNR orders entail. But I think front line doctors need to understand that they speak a different language than their patients and they must translate.
This elderly lady with pneumonia cannot be assumed. to be able to make sound decisions about her medical care.Illness can affect judgment. .Did she have a living will? If she did not have a living will, then one might consider that she has never even thought about it while mentally intact and able to make good decisions
Even if the patient is alert, able to make sound decisions, and volunteers the desire to avoid life support, it is best to discuss the situation with the family if the patient allows. It is not a good idea for the doctor to suggest to the patient that a DNR is indicated. The patient may not understand the implications of such suggestions. Best that the patient volunteer her preferences without prompting from the doctor. Then , get it in writing and have the family observe the patient's written wishes. If there is hesitation in this, you best tread very lightly .
So we touch again on bedside manner. I won't use the other word.
Very few doctors (in my experience) listen to our oldies and comply with their wishes. It is more what the family wants. And is it always the right way to go with what the family wants? I think not. We all need to stop seeing the elderly as incapable to making their own decisions. After all they ARE adults.
Thank you Dr Cifu, I so enjoy reading your essays.
I loved this humane story. 16 years ago my husband had small cell lung cancer and after chemo we returned from a trip to AZ to attend the National Championship game where Ohio State won! As soon as we got home my husband became SOB so we went to the ER. The Dr said they needed to do a C scan but he would probably go into respiratory arrest and asked if he wanted to be intubated. I made our decision yes because I thought he only had pneumonia and could be treated. When they informed me that the cancer had spread so much I went into denial. When I mentioned we had a great two week trip the Dr said that was impossible and left disappointed and sent another Dr who finally connected with me. They allowed me time to fly our son in to say goodbye. So thankful it wasn’t during Covid times!
Dr. Cifu, you are exactly the kind of clinician I want to take care of me. Actually, I was convinced of that by the great “colonoscopy debate”. I have been a nurse for 46 years. Also a nurse practitioner and educator. I’ve worked in ICU, hospice and just about everywhere.
You are so right on about this situation. The beauty of having the primary doc visit the pt in the hospital. We have lost that with hospitalists.
Somewhere in medical education today we have lost respect for the art and instinct in the practice. New docs are all about treating the labs. They can’t diagnose a simple case of colitis without imaging.
Give me an experienced doc that follows their instincts over over a well-educated, data driven younger doc any day.
Not that there is anything wrong with scientific evidence (I also have a PhD in epi), but without the instinct for pt care may as well have a bot that follows a decision tree.
My very first patient in medical school had an identical presentation, and also mid 90's but was delirious.
The next morning was sitting up in bed. Quite alert. Vital signs now normal. I walked in feeling rather proud of my care and the patients first words to me were " F#$% you!". " I had wanted to go".
The chief resident insisted the patient was simply delirious still and i should ignore him...
I have been an unlucky victim of medical paternalism in all of its autocratic misery.
Many providers have forgotten the idea of getting to know your patient, what is important to them.
When I care for patients, even when I think they need to follow my instructions, I still allow room for thought and discussion of dissenting opinions on their part. Without being angry with them or trying to shame them into compliance.
Walking beside them through whatever ails them is what we all owe our patients.
Another wonderful post. I always appreciate these.
So perfect! All of these ethical questions go out the window with your individual patient’s experiences. Paternalism to one patient is a blessed escape from 1009 decisions for another. These ethics debates cannot be had in the vacuum of a classroom and hold any value.
Cifu: "A patient, dealing with illness, in a completely foreign situation, often needs assistance articulating and applying his or her values and wishes."
Nailed it. There is a meaningful distinction between informed consent ("assent" in this exchange) and paternalism. In this particular case...
1. Dr. Z knew his patient and her values; a relatively rare thing for hospital-based physicians.
2. After offering his recommendations he still queried her wishes ("Is that alright?") and was presumably willing to honor them, even if she opted for a more aggressive course of treatment.
3. He talked with her post-hospitalization since patient wishes are often impacted by ICU stays.
Thank you for sharing this case and your humility/beginner's mind.
Thank you once again. Dana ( will be 80 in a few months)
In 1992 my hubby was diagnosed w a rare AML leukemia given less than 10% chance of living 90 days without a bone marrow transplant. We were lucky to get seven years with the wonderful team at Fred Hutch and treatment ordeal that can only astound an observer w the human body's ability to tolerate toxic assaults and survive.
The experience taught us some valuable lessons among them nearly every choice is a crap shoot. Prophylactic Rifampan w 1 in a million adverse events nearly killed him w rare allergic reaction which taught us odds matter less than individual outcomes.. We also learned antibiotic associated diarrhea is totally eliminated with some yogurt eaten a few hours after dosage to replace some healthy gut bacteria!
"If I die, you were right [about covid vaccines being dangerous]." Doug Brignole, 63 y.o., bodybuilder
https://citizenfreepress.com/breaking/bodybuilding-icon-dead-at-63/
Shall we start gathering all of the anecdotes? There seems to be quite a lot. SADS is now one of the top ten killers of under 40, isn't it? Doesn't the CDC data show that for 2021? What? You can't find the CDC data either?
Thank you for sharing that story Dr. Cifu. I think this is something difficult to teach clinicians. I am a PA in orthopaedics and teach FP residents, PAs and NPs. Granted, ortho isn’t ‘life saving situations’, but is quality of life and learning what the patient’s expectations are. I frequently find myself more in the current shared decision making model, but patients always ask, “what would you do, if it were your knee/shoulder/hip/etc.?”. I do try to be honest and not paternalistic. This story shows you need to be able to have a bit of all of the above approaches. Thanks again!
Thank you for your article. One of the biggest miscommunications I see in our healthcare system revolves around the Do Not Resuscitate order. Patient's families think if they sign it the doctors will stop taking care of their loved ones. Doctors think everyone understands that it only means they will not perform CPR or perform extraordinary measures if a person's heart stops beating. People also don't know that you can specify which extraordinary they do not want to be taken, for example no compressions, no intubation or no feeding tube. Doctors need to slow down and explain these things. Medical facilities have begun to use palliative care doctors to help in these explanations, but I do not think the facilities themselves understand the need or when to call these specialists. The Center for Practical Bioethics has a workbook, Caring Conversations, which explains medical directives, who to choose as your medical decision maker and what the DNR orders entail. But I think front line doctors need to understand that they speak a different language than their patients and they must translate.
This elderly lady with pneumonia cannot be assumed. to be able to make sound decisions about her medical care.Illness can affect judgment. .Did she have a living will? If she did not have a living will, then one might consider that she has never even thought about it while mentally intact and able to make good decisions
Even if the patient is alert, able to make sound decisions, and volunteers the desire to avoid life support, it is best to discuss the situation with the family if the patient allows. It is not a good idea for the doctor to suggest to the patient that a DNR is indicated. The patient may not understand the implications of such suggestions. Best that the patient volunteer her preferences without prompting from the doctor. Then , get it in writing and have the family observe the patient's written wishes. If there is hesitation in this, you best tread very lightly .
So we touch again on bedside manner. I won't use the other word.
Very few doctors (in my experience) listen to our oldies and comply with their wishes. It is more what the family wants. And is it always the right way to go with what the family wants? I think not. We all need to stop seeing the elderly as incapable to making their own decisions. After all they ARE adults.
Thank you Dr Cifu, I so enjoy reading your essays.
I loved this humane story. 16 years ago my husband had small cell lung cancer and after chemo we returned from a trip to AZ to attend the National Championship game where Ohio State won! As soon as we got home my husband became SOB so we went to the ER. The Dr said they needed to do a C scan but he would probably go into respiratory arrest and asked if he wanted to be intubated. I made our decision yes because I thought he only had pneumonia and could be treated. When they informed me that the cancer had spread so much I went into denial. When I mentioned we had a great two week trip the Dr said that was impossible and left disappointed and sent another Dr who finally connected with me. They allowed me time to fly our son in to say goodbye. So thankful it wasn’t during Covid times!
Dr. Cifu, you are exactly the kind of clinician I want to take care of me. Actually, I was convinced of that by the great “colonoscopy debate”. I have been a nurse for 46 years. Also a nurse practitioner and educator. I’ve worked in ICU, hospice and just about everywhere.
You are so right on about this situation. The beauty of having the primary doc visit the pt in the hospital. We have lost that with hospitalists.
Somewhere in medical education today we have lost respect for the art and instinct in the practice. New docs are all about treating the labs. They can’t diagnose a simple case of colitis without imaging.
Give me an experienced doc that follows their instincts over over a well-educated, data driven younger doc any day.
Not that there is anything wrong with scientific evidence (I also have a PhD in epi), but without the instinct for pt care may as well have a bot that follows a decision tree.
My very first patient in medical school had an identical presentation, and also mid 90's but was delirious.
The next morning was sitting up in bed. Quite alert. Vital signs now normal. I walked in feeling rather proud of my care and the patients first words to me were " F#$% you!". " I had wanted to go".
The chief resident insisted the patient was simply delirious still and i should ignore him...
I have been an unlucky victim of medical paternalism in all of its autocratic misery.
Many providers have forgotten the idea of getting to know your patient, what is important to them.
When I care for patients, even when I think they need to follow my instructions, I still allow room for thought and discussion of dissenting opinions on their part. Without being angry with them or trying to shame them into compliance.
Walking beside them through whatever ails them is what we all owe our patients.
Love this article. I’m an experienced nurse 24 yrs in a small office with a new physician.
I want so badly to emulate all that I learned working with superior physician’s in the past.
This reminds me of my training when I was first in hospital and office with my specialist.
I learned some things today. Thank you.