How we lie.

Near the end of his award-winning book, How We Die, Sherwin Nuland recounts the story of Hazel Welch, his ninety-two-year-old patient who lived at a senior citizen's residence about five miles from the Yale-new Haven Hospital. Mentally alert, Ms. Welch required nursing care because of her advanced arthritis. One day she fell and was taken by ambulance to the hospital. She was found to have a perforated digestive tract but refused indicated surgery, saying she had lived on this planet "quite long enough, young man." Nuland could not understand her decision. He told her that her chances of having a successful surgery were one in three, versus certain death without it. When Nuland returned later she relented, saying, "I'll do it, but only because I trust you."[1] The operation proved more difficult than anticipated, and when Ms. Welch could speak, more than a week later, she reproached Nuland for operating. He realized that he was wrong to have insisted on the surgery. Ms. Welch died of a massive stroke two weeks after her transfer back to her residence. Nuland Writes, "Had I the chance to relive this episode ... I would listen more to the patient and ask her less to listen to me." But, in the next paragraph, he admits that it is "a lie" to think that he would have actually acted differently, because not to operate would have risked "the scorn of my peers." He continues: It is in such matters that ethicists and moralists run aground when they try to judge the actions of bedside doctors, because they cannot see the trenches from their own distant viewing point. The code of the profession of surgery demands that no patient as salvageable as Miss Welch be allowed to die if a straightforward operation can save her, and we who would break that fundamental rule, no matter the humanness of our motive, do so at our own peril. Viewed by a surgeon, mine was strictly a clinical decision, and ethics should not have been a consideration. (p. 253) Phase I of the SUPPORT study found that physicians, like Dr., Nuland, indicated that lack of good prognostic information and a shortage of time to discuss treatment alternatives were major barriers to appropriate decisionmaking with hospitalized patients near the end of life. These problems thus became the targets of the nurse-directed Phase II intervention. But SUPPORT could succeed only if these two targets outcome information and time for physician-patient exploration of alternatives) are the true barriers to appropriate decisionmaking near death, and if they can be influenced by the activities of a specialized nurse. My own view (which finds support in the SUPPORT study) is that neither assumption is correct. The problem is the nature of hospital-based medical culture, and this culture cannot be changed by changing the practice of nurses. Physicians simply have never taken the rights of hospitalized patients seriously.[2] The most central season is that in the modern teaching hospital, patient care is often a distant third goal after teaching and research. In the high-tech, high pressure environment, there is little room for thoughtfulness, for the intrusion human values, or for conversation with the patient or family. The primary values are action- and technology-oriented; the imperative is to use all available medical technologies for the patient or for practice. As hospitals become more and more like large ICUs, this impersonal, technological emphasis increases. Add cost pressures to treat patients more quickly, and care of the dying in hospitals is likely to get worse, not better. Medical students and residents are taught that talking is a waste of time, distracting from the time available to do real medicine. And when even doing real medicine cannot help the dying patient, students and residents quickly learn that the attendings are uninterested in having discussions with patients or families about death or pain. …