Tuesday, March 08, 2005

"Should we just play along?"

In the New York Times, a hospital patient wants treatment on her own terms: "An Insurrection On the Mighty Ship of Health Care," by Dr. Kent Sepkowitz, MD.

She breaks the patients' dress code. She treats her doctor like a friendly equal. "She was notifying us that she did not intend to go along with the parade, the basic hey-everybody-let's-do-what-they-say ethos that is the organizing principle of hospital care."

She is firmly in charge. But is she also minimizing her illness? As she improves, the doc happily plays along:
Her room was my favorite stop of the day.

But then the situation soured. Her fever returned; she was sick once more. Her illness indeed was not just a minor inconvenience, a slightly bad hair day, but rather life and death, a genuine danger to her.

And suddenly everything changed. She became distrustful of us, of me. Our exchanges became awkward and hurried. I was now one of the bad guys, a willing ambassador for the dehumanizing, demoralizing, disappointing hospital.

For we had crushed her fantasy. What then became unsettling was not her antipathy (which was no fun) but rather the fact that I had agreed to play along and low-ball the gravity of the situation. I had participated in her costume ball, she in her PJ's and I in my starchy white coat. Like many others in the hospital, I was a card-carrying member of her folie à deux.

Doctors are often caught in this uneasy halfway house between medical reality and the wishes of a patient, a patient who probably knows plenty, but insists on putting on a happy face, and it raises a basic question. Is it up to us to rub a patient's face in her own frightening situation, to overwhelm the tricks and sleights of hand used to maintain sanity?

Or should we just play along. I mean there's no harm in hoping, right?

Except this. Much has been made of the problems engendered by the grim Dickensian doctor who spreads bad news with apparent glee. But what of the eternally cheerful physician, one who at times comes to resemble a used car salesman, assuring that the odd whirring noise is nothing really, nothing at all to be worried about.

Doesn't such bounciness, such resolute optimism, such eagerness to cheer up the patient at any cost finally cause avoidable harm by raising hopes on a faulty foundation?

The high-wire act required to balance hope and simple facts will remain a work in progress for years to come. But doctors and patients should remember that hope - although the most precious element in the hospital cosmos - is also the most potent. And all involved are well advised to dispense and consume it wisely.

-via blog.bioethics.net.
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