What Does "Do Everything" Mean?

At KevinMD, Lyle Fettig of PalliMed looks at a new article by Tim Quill, Bob Arnold, and Tony Black at Annals of Internal Medicine that examines how to discuss treatment with patients who say they want to "do everything." The writers suggest a plan that combats the bifurcated language patients encounter -- "do nothing," and "do everything" -- with a number of conversational steps:

1) Understand what “doing everything” means to the patient, 2) Propose a philosophy of treatment, 3) Recommend a plan of treatment, 4) Support emotional responses, 5) Negotiate disagreements, and 6) Use a harm-reduction strategy for continued requests for burdensome treatments that are very unlikely to work.

Fettig writes:

The most essential part of this process is to refrain from interpreting the patient’s request to “do everything” as a blanket consent for any medical therapy available to humankind. Rather, such a request should be considered akin to a clinical sign that requires more investigation. In step 1, the physician develops a “differential diagnosis” regarding the meaning of “everything” which includes potential affective, cognitive, spiritual, and family related factors.

The article suggests appropriate questions that help to delineate the “diagnosis” (ie the meaning of “everything”). In this step, the patient’s values, priorities, and goals are revealed. The patient knows these better than the physician. What they may not know (and what the physician should assess) is whether potential medical therapies will be consistent with values and priorities or if they will stand a chance to help them meet their goals.

(h/t Medical Futility Blog)

Mostly Dead.

Arri Eisen has this tid-bit over at Science and Religion Today:

We’ve gotten good at thwarting death, which can be good, but Western medicine, with close collaboration from science, has invented the following strange idea and carried it out beautifully: Death is failure. We are committed to keeping people alive as long as possible, no matter what. Have you heard the story of a man who was recently resuscitated by EMTs despite the fact that he had “DO NOT RESUSCITATE” tattooed on his chest?

Science and technology have forced us to think about what it means to be dead: When your brain stops? When your heart stops? When you can’t move or respond? And they have inspired us to create ways of measuring these vital signs and to invent ways of reviving them when they stop working.