I was confused by Dr Gross’s case discussion1 in The Art of Medicine until I realized that his moral dilemma was not whether he should use warfarin to prevent strokes in an elderly patient with atrial fibrillation and gastrointestinal (GI) bleeding. His real dilemma was the conflict between what our medical school training tells us to do and what our hearts tell us to do. Fortunately, palliative medicine is now teaching us that we can follow our hearts and let go of these dilemmas. I believe the case presented is a perfect example.
In the case discussion a woman, Mrs Lopez, had multiple strokes. GI bleeding was a complication of warfarin therapy and a possible malignancy. Dr Gross’s heart told him not to be too aggressive in his testing and treatments. Mrs Lopez and her family agreed “not to embark on an elaborate search.” What was missed, perhaps, was the opportunity to more fully discuss her directives for care. What was also missed at the time was the identification that Mrs Lopez was terminally ill. She was terminal because her life was clearly coming to an end. The ability to cure and fix was no longer realistic. Some of her directives were clear: Dr Gross mentioned that Mrs Lopez accepted life’s uncertainties. Her philosophy seemed to be summed up in the phrase: What will be, will be. So a reasonable choice was palliative care, with an aggressive focus on keeping her comfortable and controlling distressing symptoms. GI bleeding is emotionally distressing and can cause weakness, fatigue, dyspnea, and chest pain, if coronary artery disease is present. The moral principle of “do no harm” would uphold the decision not to give her anything (such as warfarin) that increased the risk of GI bleeding. Aspirin might have been included in this decision, especially given aspirin’s limited possible benefit. Transfusions were appropriate treatment for the anemia resulting from the bleeding. Repeated strokes confirmed the terminal nature of her condition. She might die with the next stroke or she might live to have another one. As Mrs Lopez said, “Si dios quiere.”
The goals to reduce suffering, to control her symptoms, and to maximize her comfort could have made Dr Gross’s dilemma disappear. With these goals in mind he might have reacted to the next stroke in a different way. The goals and the ethical principles of beneficence and doing no harm would have supported his decision not to admit her to the intensive care unit again. The time for cure and fix was past. Central lines and nasogastric tubes were inappropriate for the patient, who was terminal and now hoped for a peaceful, comfortable, dignified death. Dr Gross did come to this realization. But he could have avoided the emotionally charged decision to discontinue Mrs Lopez’s treatments by not starting them.
Death need not be the enemy physicians hide from at all costs. Death is part of life. Physicians can help their patients and families a great deal by recognizing when the dying process is starting. The dilemma described by Dr Gross reflects physicians’ reluctance to let go of curing and fixing as the only goals of care. The principles and philosophy of palliative medicine can help physicians get out of apparent moral clinical dilemmas, especially those based on different treatments aimed at fixing what cannot be fixed. Palliative medicine goals remove the dilemma by upholding the physician’s role in looking at the whole patient, the whole picture, and recognizing the need for appropriate end-of-life care. Planning a good peaceful death may create the perfect outcome.
George F. Davis, MD
Albany, New York
- Gross PR. A rock and a hard place. J Fam Pract 2000; 49:863-64.
The preceding letter was referred to Dr Gross who responded as follows:
I applaud Dr Davis for drawing attention to the value of palliative care. I’m afraid, however, that in his eagerness to prescribe palliative care to resolve the quandry I described, he missed the exact location of the “rock and hard place” I spoke of.
My dilemma was not so much a conflict between “what our medical school training tells us to do and what our hearts tell us to do”; rather, it was an uncertainty within my own heart and mind as to which course of action would lead to a better life for my patient.
In this situation—an elderly patient with atrial fibrillation and gastrointestinal bleeding—both heart and medical training speak with 1 voice: Do not anticoagulate. The dilemma is that this clear choice carries its own substantial risk—a stroke that can cripple if it does not kill. After she suffered 1 stroke, then 2, I worried that Mrs Lopez’s next event could lead not only to death but to months of hemiparesis before she perished—and wondered whether I was doing all I could to avert that disaster. Therefore, the thrust of my piece was that clinical uncertainty leads us to second-guess high-stakes decisions, and even wise choices can lead to unhappy outcomes.