Month: September 2017

An illustrated history of truth in medicine

Who isn’t completely honest with patients?

Memorial Medical Centre after Hurricane Katrina, New Oleans

Some years after Hurricane Katrina (2005), I read an excellent book, Five Days at Memorial by Sheri Fink, about the alleged actions of medical staff who looked after patients in the flood-stricken Memorial Medical Centre. They were accused of administering sedatives and opiates with the intention of hastening death, i.e. committing euthanasia. Immobile, comorbid and very dependent patients in the Lifecare facility stood no chance of being evacuated via the helipad, and as conditions deteriorated in the heat, they began to suffer. The details and follow up to this investigation can be read here.

 

Emmett Everett, died in MMC and found to have non-prescribed sedatives on board at post-mortem

This was about more than words, obviously, but the scenario of doctors administering drugs without their patient’s knowledge, ‘for their own good’, led me to investigate the history of truth in medicine. I spoke on the subject to a meeting of the West Kent Medico-Chirurgical Society, and this essay is based on that talk.

 

Route to the helipad, MMC

 

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We start with an ancient story: Arria, a Roman woman, regularly visited her husband, Caecina Paetus, who had been imprisoned by the emperor Claudius. During this period, their sick son died and was buried, but Arria chose to hide this information from her husband – to spare him the pain. Pliny wrote that when she felt the sadness begin to overcome her in his presence, she took herself away so as not to reveal the truth.

 

Arria and Paetus. Later, he was ordered to kill himself by Claudius, but could not do it. So Arria took the knife, stabbed herself, cried ‘Paetus, it does not hurt’, and died. He then carried out Claudius’ sentence on himself.

 

An early example of deception for the (perceived) good of another. And a behaviour that may be relevant to doctors and nurses who sometimes know a great deal more about the details of their patients’ condition, and their likely fate, than their patients do.

 

Antiquity to industrial revolution

Hippocrates

The fathers of medicine saw a place for withholding truth. In the ‘Decorum’, dubiously attributed to Hippocrates [460-370BC], it is written,

Perform your medical duties calmly and adroitly, concealing most things from the patient while you are attending him.

 

Galen

 

Galen [130-210AD] described ‘δειλός’, the state of fear and anxiety about ones health that should be avoided as much as possible.

Arnald de Villanova [1240-1311], a Spanish physician, stated,

Arnald de Villanova

Promise health to the patient who is hanging on your lips,

but once you have left him say some words to the members

of the household to the effect that he is very ill;

then if he recovers you will be praised more…

 

Page from ‘Chirurgia’

And the famous surgeon Henri de Mondeville [1260-1320] wrote, in his treatise ‘Chirurgia’,

He should promise a cure to all his patients, but not conceal the danger of the case, if there is any, from the family and friends…

 

 

500 years later however, the words of Samuel Johnson [1709-1784] were reported by Boswell,

Clearly he supported full disclosure, mainly due to personal experience.

 

Thomas Percival

Manchester cotton factory

In the early 19th century Dr Thomas Percival was asked to help settle a dispute between apothecaries, physicians and surgeons at the Manchester Royal Infirmary. Percival had done great work in analysing bills of mortality and improving working conditions in the cotton mills.

In 1803 he published ‘Medical Ethics, or a code of institutes and precepts adapted to the professional conduct of physicians and surgeons’. Appearing to err on the side of protective optimism rather than painful honesty, he wrote,

‘A physician should not be forward to make gloomy prognostications, because they savor of empiricism… the physician should be the minister of hope… It is, therefore, a sacred duty to guard himself carefully in this respectm and to avoid all things which have a tendency to discourage the patients and depress his spirits.’

 

Manchester Royal Infirmary, opened 1755

 

A little later, 1849, the American physician Worthington Hooker [1806-1867] wrote ‘Physician and Patient, or, a practical view of mutual duties, relations and interests of the medical profession and the community’. In Chapter XVII, titled ‘Truth in our intercourse with the sick’, he writes,

 

Worthington Hooker

 First, It is erroneously assumed by those who advocate deception, that the knowledge to be concealed…would be injurious

Secondly, it is erroneously assumed that concealment can always… be effectively carried out.

Percival’s Medical Ethics

Thirdly, if the deception be discovered or suspected, the effect upon the patient is much worse…

Fourthly, the destruction of confidence… [has] injurious consequences to the persons deceived

Even though Hook was beginning to challenge the tendency to conceal, individuals assumed that deception was an intrinsic medical skill well into the 20th century, as this 1927 quote  from Collins demonstrates,

‘the longer I practice medicine, the more I am convinced that every physician should cultivate lying as a fine art’

 

 

Nuremberg and autonomy

By the mid-20th Century, everything had changed. Under the Nazi’s, medicine was consumed by evil. Dr Karl Brandt [1904-1948], Hitler’s “Escort Physician” and latterly Commissioner of Sanitation and Health, oversaw a systematic euthanasia programme, and  widespread medical experimentation. Looking at his fresh face at a gathering of the elite in Berchestgaden, it is still difficult to understand how doctors such as he, trained to heal, could have drifted so far into the moral swamp. He was tried at Nuremberg and hung at the age 44 (having previously been sentenced to death by the Nazis for helping his family escape from Berlin to surrender before the city was overrun).

Nuremberg

 

Karl Brandt, on trial and in his pomp

 

From Nuremberg emerged principles, the Nuremberg Code, that guide us today. These include, as regards medical interventions,

  • The voluntary consent of the human subject is absolutely essential…
  • …exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of constraint or coercion…
  • should have sufficient knowledge and comprehension of the elements of the subject matter involved as to enable him/her to make an understanding and enlightened decision.

 

The last one is key. For consent to be valid, the person, or patient, must know everything. Consent, in this context, is a corollary of autonomy, probably the stoutest pillar in the ethical framework that doctors refer to on a day to day basis. Tom Beauchamp and James Childress, working in Healy Hall, Georgetown University, Washington, wrote Principles Of Biomedical Ethics, containing the now familiar touchstones:

Autonomy – The right for an individual to make his or her own choice.

Beneficence – The principle of acting with the best interest of the other in mind.

Non-maleficence – The principle that “above all, do no harm,” as stated in the Hippocratic Oath.

Justice – A concept that emphasizes fairness and equality among individuals.

 

 

Two judgments

Respect for autonomy requires full disclosure of the relevant facts, so that patients can make an informed decision. This seems simple. Yet, even today, we sometimes struggle with it.

The case of Janet Tracey, about which I have written on this blog before, is an example. A doctor issued a DNACPR notice without, in the opinion of the judge, offering in a meaningful way to discuss it with her.

He said,

“On occasions when I attempted to initiate discussions with Mrs Tracey regarding her treatment and her future she did not want to discuss these issues with me.”

 

The Tracey family outside the High Court

 

The argument, that in this case it would have been cruel to press her to discuss the subject, did not wash. In fact the judge doubted that the doctor had tried as hard as he said.

‘In the absence of any documentation and in the light of what is known about Mrs Tracey’s view on the issue of resuscitation around the time of the first Notice, I am unable to accept Dr ______’s evidence that he spoke to Mrs Tracey about resuscitation prior to the implementation of the first DNACPR Notice.’

And in his summary, the judge said,

‘It may well be that such a concern also caused him to spare her a conversation which he knew was likely to cause distress to a suffering patient.’

‘…doctors should be wary of being too ready to exclude patients from the process on the grounds that their involvement is likely to distress them.’

So, the opinions of those wise men who favoured concealment of harsh truths have been challenged, and overcome. Now, especially towards the end of life or the context of surgical procedures, it is clear that full disclosure is required. To do otherwise is rarely justified.

 

Sam and Nadine Montgomery

 

The Montgomery case has further nuanced our approach to providing information. Nadine Montgomery agreed to a vaginal delivery, even though her baby was large compared to the mother (who was diabetic, a risk factor for having larger babies). The baby became stuck in the birth canal and suffered a brain injury. The Supreme Court found that the risks of vaginal delivery in this particular case had not been explained adequately, and that if they had Ms Montgomery would definitely have opted for a Caesarean section.

The judgment, which is fascinating to read, includes a critical reference to the Bolam case, which was one of  the precedents on which consent use to rely. Under Bolam, doctors had to say as much as a group of peers in similar circumstances would generally have said (this always seemed quite a circular argument to me).

Furthermore, because the extent to which a doctor may be inclined to discuss risks with a patient is not determined by medical learning or experience, the application of the Bolam test to this question is liable to result in the sanctioning of differences in practice which are attributable not to divergent schools of thought in medical science, but merely to divergent attitudes among doctors as to the degree of respect owed to their patients.

The judge then emphasises the need to tailor the information they give to the individual,

This role will only be performed effectively if the information provided is comprehensible. The doctor’s duty is not therefore fulfilled by bombarding the patient with technical information which she cannot reasonably be expected to grasp, let alone by routinely demanding her signature on a consent form.

Many say that good doctors have been discussing risks with their patients like this for years anyway, and now the ‘law has caught up’. But we can see how a tendency to paternalism, to partial transparency, has grown from the historical instinct to withold information. There may still be exceptions. In emergency scenarios, where the patient is vulnerable, or cannot focus on the facts, and decisions must be taken, doctors are quick to fall back on ‘best interest’ thinking. This requires an objective assessment of what is best, and a rapid discussion within the team (often led by the clinician, who will tend to drive the direction of travel). As the figure below illustrates, with increasing urgency the amount of information, and therefore the degree of autonomy permitted, may reduce.

 

 

These situations place a great power, and burden, in the hands of decision makers. It is essential that outside these ‘lifesaving’ situations, clinicians revert back to the habit of sharing information, and ensuring consent is truly informed. As we know from the good Dr Hooker’s third observation on the matter of truth – ‘if the deception be discovered or suspected, the effect upon the patient is much worse…’. Nowadays, that effect will result in more than suffering for the patient, but a professional or legal challenge to the doctor in question.

 

 

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Picture credits:

Route to the helipad – diagram of hospital taken from ‘5 days at memorial’

Tracey family, copyright Roland Hoskins

Emmett Everett – from CNN interactive website

Others – commons license

 

Further reading:

I became interested in this subject, having found myself ‘spinning’ prognostic estimates in the intensive care unit, whether consciously or unconsciously, while speaking to relatives about the best way forward. In a paper, ‘Sophistry and circumstance at the end of life’ (Pubmed abstract), I explored language choices made during these discussions. For instance, a 95% chance of dying sounds bad, and seems to meet the standard for futility; but choose to present that as ‘a 1 in 20 chance of survival’, and it doesn’t sound so hopeless. Doctors may use language differently according to their therapeutic agenda.

In a second paper, ‘The witholding of truth when counselling relatives of the critically ill: a rational defence’ (PDF), I reviewed some literature on the subject of truth-telling, and explored how being less than frank about poor prognosis can sometimes be justified.

The literature regarding truth in medicine is extensive, and this paper by Catriona Cox and Zoe Fritz is a good introduction with many helpful references.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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In my day

Reading about the situation at Derriford hospital, where two doctors found themselves responsible for over 400 people, I thought about my own training in the 1990s. Before you slap the computer shut or throw down the phone, I should say that although there is a fair amount of ‘in my day’ reflection here, it is not my intention to promote a ‘just get on with it’ attitude.

Back in the 90’s few if any junior doctors thought about challenging potentially dangerous staffing levels. If we turned up to the hospital on a Saturday morning to find that we were one doctor down, we steeled ourselves for a nightmare and hit the wards determined to fight the fires as they arose. If people died, we attributed their demise to disease, not to a paucity of doctors. Overnight, in the large hospital where I started work, two JHO’s and one SHO* managed all the medical wards and all medical admissions after seven o’clock. The Registrar went home at ten. The consultant was not seen until the 8AM post-take round. That was just how things were. It seemed hard, it felt threadbare, but we did not complain.

Our perspective was centred on our own experience, not that of the patients. As the sun rose to brighten the night-blackened windows after a non-stop night, and the nurses handed over to the early shift, we congratulated ourselves for having responded to the many calls, requests and emergencies that had arisen. The euphoria of finishing the shift counteracted any misgivings we may have had about sailing too close to the wind at times. We felt like heroes. In the pub, we spoke about working in ‘warzones’.  We weren’t happy with it, and the hours before a series of weekend on-call shifts could become heavy with foreboding, but we managed.

If a patient deteriorates during a period of sub-optimal staffing, it is very hard to link their outcome with the number of doctors available. The sick get sick, that is why they are in hospital. Doctors are good at focusing their time and energy on those who need it most, so of those 400 and more patients in Derriford, perhaps twenty will have required urgent medical assessment and a new management decision over an eight or twelve-hour period. The stable majority were looked after by nurses, who could alert the doctors to any signs of deterioration if they developed. It is rare for two or three patients to get acutely ill simultaneously, such that a doctor cannot physically be with a patient during an emergency.

But what if that does happen? A doctor might have to run away from one patient before he or she has sorted them out, to see another one who was just deteriorated. If there are only two doctors, and six simultaneously sick patients, it would appear that a difficult choice has to be made, and the least deserving will go neglected. This is extremely rare. When the alarm goes up, other colleagues (anaesthetists, outreach teams, even orthopods) emerge from the ether. The system stretches. The need is met. So at the end of the day, nobody seems to suffer. There are no ‘serious incidents in which the root cause is felt to be under-staffing. And the patients… they would have had no idea the team was a doctor or two down. So what exactly is the problem?

Well, there was risk. There was probably delay in seeing patient, and perhaps some associated morbidity – but none that could not be measured or proven. And the doctors, for all their coping ability, were strung out, and felt vulnerable. The price to pay for a system running at full stretch is the potential for disaster, stress, a poor learning environment, disillusionment and ultimately burnout. Yet many of us saw this during our training, and said nothing. We were in the problem so deeply, we didn’t see it as a problem. Or perhaps we didn’t have the ability a look up and gain a broader perspective.

Today junior doctors are more vociferous, and, in certain circumstances, more militant. The industrial action that took place last year was the clear example of this. Unsatisfactory staffing levels and training opportunities are now challenged. They do not regard those difficult shifts as a heroic challenge, but as failures of the system which they, the doctors, have a responsibility to highlight. This involves informing management and pressing for locum cover, providing feedback freely and without fear through GMC surveys and empowering their BMA representatives.

Why the change? I think junior doctors are more mature nowadays. Many have competed degrees before entering medicine, or have pursued different careers. They may be more independently minded. As a 24-year old in my first teaching hospital, I was grateful to have been selected for a ‘good’ post. I saw the challenges ahead in terms of my ability to meet them, to avoid failure however steep the learning curve… not to question the organisation itself, or the wider political environment. Therefore, during those years when I worked to the limits of my ability in understaffed areas, I did not complain. I did not seek to improve patient safety by making a fuss. I was, in a way, complicit.

Old attitudes don’t fall away easily. When I hear about an understaffed shift now I worry, and I sympathise, but a hard part of me thinks, ‘They’ll manage. They always manage…You know, back in the 90’s…” etc., etc,, yawn, yawn.

The future requires doctors like me, who appear to have grown older and perhaps a little cantankerous, to recognize that what was once acceptable is no more, and that without fuss, there is no change.

*JHO, junior house officer – first year post-qualificiation; SHO – senior house officer – 2nd or 3rd year post qualification