Primum non nocere
Pietro Miozzo
Hospital day 1: Mr. S, 84 year-old male with new diagnosis of acute myelogenous leukemia. Given the option of high-dose chemotherapy that is likely to cure him, he opts to pursue aggressive treatment rather than allowing his disease to run its natural course.
Hospital day 2: Mr. S, 84 year-old male with new diagnosis of acute myelogenous leukemia. Preparing to undergo chemotherapy. Has decorated his hospital room, in anticipation of spending a month going through a 21-day cycle of chemotherapy. Waiting to meet with clinical research team to discuss further treatment options.
Hospital day 3: Mr. S, 84 year-old male with new diagnosis of acute myelogenous leukemia. Has decided to pursue experimental treatment. Will receive first dose today.
Hospital day 4: Mr. S, 84 year-old male with new diagnosis of acute myelogenous leukemia. Spiked a fever of 38 C today. Cycle 1 day 2 of chemotherapy.
Hospital day 5: Mr. S, 84 year-old male with new diagnosis of acute myelogenous leukemia. Cycle 1 day 3 of chemotherapy. Febrile, hypotensive, tachycardic, somnolent, acidotic. Admitted to unit. Code status changed to DNR/DNI, comfort care only. Time of death: 10pm.
The case of Mr. S, an older gentleman newly diagnosed with AML (initially discovered because of an abnormal CBC), initially appears unremarkable. That is, until we run the clock and follow his trajectory from what is a curable disease to his rapid decline and death. Mr. S, 84 year-old male with new diagnosis of acute myelogenous leukemia—a routine diagnosis, a routine treatment, a curable disease, a forgettable opening sentence to a presentation on rounds. However, for Mr. S, it was none of these things.
What is perhaps a routine diagnosis with a routine treatment for the physician is likely not so for the patient. It was confusing and distressing at times to see the extent to which diagnoses and complex treatment regimens were thrown at patients during rounds. And it was clear, given the look of bewilderment on some of their eyes, how little the patients understood or were able to comprehend at that moment. We may explain things in a perfectly understandable fashion, but when given a serious diagnosis or a complex plan, the patient may not be able to listen attentively and truly digest the information presented. Mr. S understood the severity of his disease, and maybe even some of the risks involved in the treatment. But given the possibly unrealistically optimistic reassurance that complications are infrequent, he decided to pursue aggressive treatment. Was he misled about the likelihood of failure of treatment or even devastating consequences? Was the attending too cavalier or unwilling to entertain the possibility of failure? Or did we just see a healthy-appearing 84 year-old male, someone who could easily have passed for a man in his sixties, and assume that he was in fact healthier and more vigorous than he truly was?
As medical practitioners, one of the traditional pillars of our profession is Primum non nocere. Yet, we have the power to do good and the power to do harm. After all, is it truly possible to do no harm, even when we administer powerful agents such as chemotherapy drugs? All medications and other interventions have inherent risks and benefits. But when something like chemotherapies, which are the most literal poisons in our pharmaceutical arsenal, become so “routine,” it is easy to forget their potential for devastating consequences. I am not sure how to balance not becoming complacent regarding such risk, while at the same time not being paralyzed by fear of negative consequences. My experience with this patient suggests that we must always be open to the possibility of failure, and not anchor on the assumption of success.
Our team found out about Mr. S’s passing the next day before rounds. I could sense that there was no surprise in the news, given the events of the previous day. But what struck me was that we didn’t seem to be able to move on. Several patients passed on during my time on the hematology-oncology service, and for the most part we would not dwell too much on their death. These were patients who came into the hospital sick, not ones who looked two decades younger than their actual age. These were patients who had exhausted all options for curative treatment and who were awaiting death. With Mr. S, the surprise was not that he was dead, but that he had taken a turn in the first place. We could not help but wonder whether he would have been better off not pursuing curative treatment in the first place, and enjoying a few good months with family.
In this situation, it was hard to find the exact emotion. My senior resident was angry that the attending had forged forward so aggressively, saying that she thought the attending only saw his younger appearance and held onto false hope. The intern following the patient was shaken by how quickly things deteriorated, and how it was the treatment and not the disease that ultimately caused the most harm. And I was frustrated because this was not the first time that I had witnessed a patient putting all of his trust in the physician’s hands, seeing her as the only hope, only to be worse off than the start.
As a physician-in-training, and as someone interested in oncology, it is challenging to see the degree to which patients elevate their oncologists, and the extent that oncologists are often unrelenting in their pursuit of treatment and unwilling to accept the alternative. I know that it will be difficult for me to fully reconcile wanting to create the best outcome for my patient while having the courage to pursue potential miracle cures.
Mr. S, 84 year-old male with new diagnosis of acute myelogenous leukemia: Thank you for allowing me to perform my first ABG. I wish you never would have needed one. We can’t predict what would have happened if we’d made a different decision about your treatment, and I will keep wondering if things could have turned out differently. But your case taught me that we must live with that uncertainty if we are to be able to treat other patients and not be constantly stuck at “well, what if?”
Pietro Miozzo is a fourth year medical student who will be starting residency in pediatrics at MGH this summer. He is interested in mindfulness and how reflective writing can help clinicians build resilience.
