But Doctor, What Do YOU Think I Should Do?

I’ve been thinking about this a lot lately, so I thought I would write a blog about it!  I’d love to know what you think :-)

Being part of a healthcare team for a patient is an honor and a privilege.  A patient invites you into their lives and shares their most intimate health information with you.  Sometimes they share personal conflicts, family and financial troubles, fears, and failures.  They not only trust you with that information, but they rely on you to help them make decisions in their best interest.

The four pillars of medical ethics are beneficence, non-maleficence, justice, and autonomy.   Beneficence is the commitment we all share as medical providers to “do good”.  Non-malefience is the age old oath from Hippocrates we take to “do no harm”.  Justice is to treat all patients fairly and with the same consideration you give to everyone regardless of race, religion, age, financial status, or even your personal opinion of the patient.  Justice stands for equality in treatment.  I struggle with this one because so much of the medical system is unjust.  You get better healthcare when you have insurance, when you live in a developed country, etc.

Hippocratic-oath

Autonomy is the ethical principle that each patient has the right to make their own medical decisions.  Medicine has a long history of being quite paternalistic.  You do what the doctor says without question.  I am a STRONG advocate of patient autonomy.  I truly believe that a patient should be able to make their own medical decisions and do what they want.  It’s their body, their life, and they have to live with the consequences of the medical decisions they make.  I should not be the one to make those decisions, because in spite of my medical knowledge and experience, I know nothing about an individual patient’s life and what each medical decision might mean specifically for them.

We had a practice session with standardized patients during orientation last month, and one scenario involved talking about code status with a patient.  Code status means whether the patient would like to be fully resuscitated in the event of cardiac arrest (Full Code) or whether they would like to let nature take it’s course should their heart stop or should they stop breathing (Do Not Resucitate/Do Not Intubate).  Clearly, the code status differs greatly between patients depending on their age and health.

If I were to suddenly drop dead from cardiac arrest, I would want everything done- CPR, cardioversion (shocking my heart), and even putting a breathing tube down my throat.  I’m 26 years old and the likelihood of me recovering from a catastrophic event like that is fairly high.

If a 90 year old with end-stage lung cancer were to be found without a pulse, the likelihood of them surviving a code is extremely low.

In fact, studies have shown that only between 10 and 20% of patients who code in the hospital end up leaving the hospital alive.  An even lower number leave without any long term neurologic deficits.

When I had the conversation with the standardized patient about code status, she had metastatic breast cancer.  It was my personal opinion that she should be DNR/DNI because the probability of her surviving a code is so low.  It’s possible that if she were “full code” she could die in an ICU with a breathing tube down her throat, heavily sedated and unaware of her surroundings.

But when she asked me, “What would YOU do?”  I told her, “I can’t answer that for you.  That is your decision to make”.  I told her that because I believe so strongly in patient autonomy.  I don’t know her background and I shouldn’t make that decision for her.  Throughout all of medical school I always believed it was wrong to tell the patient your opinion.

Well, I have completely changed my mind.  I have come to believe that now that I am a doctor, I have medical knowledge and clinical experience that make my opinion worthwhile to patients.  While I would never try to coerce a patient into what I thought, I think there is value in what I would do.  I think patients come to their doctors for medical advice and I now realize that you can respect patient autonomy while still telling the patient what you think or what you would do.

For every new admission to the hospital, I ask them about code status.  I now find myself having different conversations depending on what I think clinically would be best for the patient.  I’ve had a few healthy patients in their sixties ask about DNR/DNI.  They tell me they don’t want to “be a vegetable.”  I explain to them that sometimes there are reversible causes of cardiac arrest or reversible things necessitating intubation.  I’ve seen patients come in septic and need to be intubated.  After a few days of antibiotics they are extubated and go home.  Had that person been DNR/DNI, that would have been it for them.

I’ve also found myself comforting patients who decide to be DNR/DNI by telling them that in my experience I think that is a good decision for them.  I recently had a patient who was originally ‘Full code’ but suffered a devastating stroke.  We had a family discussion in the hospital and changed them to DNR/DNI.

I think that having these discussions can help patients chose a plan of care that is right for them.  It can help decrease the number of people who die in the ICU (did you know that 1 in 6 people in the USA will die in the ICU?).  It can help decrease costs spent prolonging life that the patient might not have even wanted.  It can also help comfort patients and their families.

I’m glad that I’m learning how to respect patient autonomy while still giving advice.  Counseling patients truly is an honor and even though I’m a brand new doctor, I hope I can contribute to their care.

What do you think?  Do you want your doctors to tell you what they think?  

Have you ever had to discuss code status with family members or friends? 

20 thoughts on “But Doctor, What Do YOU Think I Should Do?

  1. I genuinely appreciate when a doctor gives me their personal opinion. When I was having knee surgery (I know it’s not even remotely as serious as DNR/DNI), I had to make a decision on what operation I wanted done. My doctor told me that if I was his daughter, he would make this certain decision. That was incredibly helpful and comforting to me. I’m not the professional, so the doctors usually know best. I think DRN/DNI would be a hard topic to discuss, but I think you’re doing a great job!:)

    • Yes exactly!! I think it really is valuable to say your opinion when a patient has a choice to make- like surgery! Such a good example. I’m glad you were comforted by your doctor!

  2. I love your thinking! Thank you so much for sharing.
    You gave me a new perspective and I hope you post more stuff like this when you have time!

  3. Soooooooooooo hard! I do want the doc to be honest with me BUT I have had the opposite with my dad when he was in a religious hospital & did not want to honor the DNR/DNI for us. Lucky we had one doc that fought for us. I think it is important to find a doc you trust & ask for their honest opinion.

    The system is crazy in this country when they would let people die if they don’t have coverage or enough money for the best care.

    I just got the Health Initiative care – thankful for it & President for it BUT with the preventative exam,you can’t ask any questions or you get charged for it – I had lots of questions since I had not gone in years but I could not afford to pay more right now… still things to work out here for sure!
    Jody – Fit at 56 recently posted…Some Truth & Inspiration for Friday!My Profile

  4. Hi Andrea,
    been reading your blog for a while and I must say I find it inspiring. I admire your discipline and dedication to what you do.
    As someone who works in healthcare as well I’ve found that patients ask us about our opinions quite frequently. Even as a nursing student (a first year BSN at that

  5. Thanks for the touching post… I agree that we go see the expert because we value their opinion. Last year I was about to buy a used car and I took it to a mechanic for a check and he said to be honest if you were my daughter I wouldn’t let you buy this car. I appreciated his opinion so much, especially when it was phrased in such a non-authoritarian way! I think patients value the same approach from their doctors, making high stakes medical decisions is so hard, I think patients find it comforting to know what a medically trained person would do for themselves in the same circumstance.
    Phillippa recently posted…Sunday Adventures, Healthy Dinner Ideas and Week Two DoneMy Profile

  6. I absolutely loved this post–so interesting! I would love to hear more from you about other ethical controversies in the medical field :)

  7. One of the first things I do every day is look to see if you’ve updated your blog!! I love hearing your stories and ideas!

    On the topic of patient autonomy, I agree with you. The idea that a patient needs to make their own decision is true, but it is important that they have the information to make that decision. The doctor’s role, in my opinion, is to provide that information. It’s impossible to do this completely without bias (although we would like that!), so I believe that as long as you truly have the patient’s interest at heart, giving your opinion is the right things to do.

    In anything you do in life, you need to trust others who know more about the subject to give you their opinion. I ask my mom her opinion on most important decisions in my life. I definitely do not always make the same decision she would make, but I do consider her viewpoint. Asking someone’s opinion and blindly following it are different.

    It is a really difficult thing, though, because there are a lot of patients that will just follow whatever you tell them. And I think part of that, too, is that they don’t want the responsibility of making the decision, either. It’s really a tough balance!

  8. Hey Andrea!

    Love your posts! Thank you so much for offering help and guidance to those of us also in the medical world!

    I’m a fourth year medical student, and I wanted to know if you had any advice on how you have been studying during residency? (ex. Do you pick a topic that you saw that day and review on it?)

    Thanks!! :)

    • Hi Sarah! Congrats on 4th year! It’s such a great year! Uhg, I have been doing a terrible job of studying in residency. I still haven’t found a great system. I am trying to really learn a lot throughout the day and ask questions so I learn as much as possible while I’m at the hositpal, but I haven’t made a good reading plan or anything. I will let you know if I figure out a good system!

  9. On a recent post you discussed your sleep cycles and posted a picture from your fitness tracker. What fitness tracker do you use? Do you like it? How’d you choose it? Is it accurate? Review!

    • Hi Jasmine!! I use the FitBit! I will definitely post a review! That’s a great blog idea. I think it’s pretty accurate, although I hate seeing how few steps I get during a day on call when I feel like I’m running around the hospital all day- I always think I will have tons of steps, but alas, I don’t even hit 10,000!! Dang!

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  11. Hi Andrea, great post! I completely agree that doctors should be able to answer “what would you do?” question without infringing on patient autonomy. After all, many critically ill patients and their families are already struggling emotionally to understand their prognosis and care decisions. Getting an honest opinion from the doctor, I think, humanizes the situation a little bit more. As well as ensuring that patients and families truly understand goals of care and their implications, doctors can help ease the emotional pain and stress that patients and their families experience. Glad to see your residency is getting off to a great start!

    Rebecca
    Rebecca @ C’est Si Bon MD recently posted…Mini Ice Cream SandwichesMy Profile

  12. I 100% agree with you – in our SIM labs/standardized patient encounters, I’ve always tried not to express too much of my opinion or what I would do. Our school stresses medical ethics heavily and we’ve talked a lot about respecting patient autonomy. (Side note – Have you read The Good Doctor? It talks about paternalism vs. patient autonomy from a father/son physician perspective – I want to read it!). I learned from working as a nurses aide, however, that patients and families do want guidance and help with their decisions. I think your approach makes sense – don’t try to push them into a decision but rather present what your best clinical judgements.

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