THE seemingly easiest and most sensible rule for a doctor to follow is: always fight. Always look for what more you could do. I am sympathetic to this rule. It gives us our best chance of avoiding the worst error of all 鈥� giving up on someone we could have helped.
However, it doesn鈥檛 take long to realise that the rule is neither viable nor humane. All doctors have patients they are unable to heal, or even to diagnose, no matter how hard they try.
I was walking down the hallway one day when Jeanne, one of the intensive care unit nurses, stopped me, visibly angry. 鈥淲hat is it with you doctors?鈥� she said. 鈥淒on鈥檛 you ever know when to stop?鈥�
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That day she had been caring for a man with lung cancer. He had had one of his lungs removed and had been in intensive care for all but three weeks of the five months since. A pneumonia that blossomed in his remaining lung early after surgery had left him unable to breathe without a tracheotomy and a respirator. He had to be heavily sedated or his oxygen levels dropped. He received nutrition through a surgically placed gastric tube. Sepsis claimed his kidneys and the team put him on continuous dialysis.
It had long ago become apparent that a life outside the hospital was not possible for this man, but neither the doctors nor his wife seemed capable of confronting this truth 鈥� because he did not have a terminal disease (his cancer had been removed successfully) and he was only in his fifties. So there he lay, with no evident hope of progress and his doctors simply trying to keep him from falling back.
As we talked, Jeanne also told me of doctors she thought had stopped pushing too soon. So I asked what she felt the best doctors did. She thought for a while before answering. Good doctors, she finally said, understand one key thing: 鈥淭his is not about them. It鈥檚 about the patient.鈥� The good doctors didn鈥檛 always get the answers right, she said. Sometimes they still pushed too long or not long enough, but at least they stopped to wonder, to reconsider the path they were on. They asked colleagues for another perspective. They set aside their egos.
This insight is wiser and harder to grasp than it might seem. When someone has come to you for your expertise and your expertise has failed, what do you have left? You have only your character to fall back upon, and sometimes it鈥檚 only your pride that comes through. You may simply deny that more can鈥檛 be done. You may become angry. You may blame the person 鈥� 鈥淪he didn鈥檛 follow my instructions!鈥� You may dread just seeing that person again. I have done all these things. They never come to any good.
In the end, no guidelines can tell us what we have power over and what we don鈥檛. In the face of uncertainty, wisdom is to err on the side of pushing, to not give up. But you have to be ready to recognise when pushing is only ego. You have to be ready to recognise when the pushing can turn to harm.
In a way our task is to 鈥渁lways fight鈥�, but our fight is not always to do more. It is to do right by our patients, even though what is right is not always clear.
