Sunday, October 24, 2010

First Do No Harm

One of the ancient principles of medicine is Primum non nocere, the Latin phrase that means "First, do no harm".  It means that sometimes doing nothing is a better decision than doing something that might cause more harm than good.  It is an ethical precept for physicians, but it becomes harder and harder to adhere to as more and more exotic tests and treatments are at our disposal. 

But just because we can do tests or surgery, doesn't mean we should.  Looking at the whole patient; their lifestyle, beliefs, support system and activity level, should be part of the analysis and decision.

There are so many ways and times in treating patients, that doing nothing can be the best decision.  A prime example is Mr. Leon Sanit who is 97 years old.  Mr. Sanit lives in Los Angeles and plays tennis every single day at 11 A.M.  He was diagnosed with bladder cancer and doctors recommended surgery that had a 50% chance of extending his life.  Here is a guy with an active life,  playing tennis at age 97, who has wisely decided to forgo surgery and just enjoy himself.

The risks of surgery in a 97 year old are considerable.  The convalescence and recovery itself are risky and would certainly impact the good time he has left in his life.  The odds of him ever being back on the tennis court are considerably lower than the chance he would live longer.  

I know of another elderly man (a friend's father) who had prostate surgery for prostate cancer, even though he was over 80 years old and had a lower Gleason score, which means it is a slower growing form of cancer.  I was upset to learn his physicians had recommended surgery.  He had a bad post op course and never really returned to his pre-op activity level.  He died within a year of the surgery. Doing something, was worse than doing nothing.

One way patients can help a doctor stop and consider the recommendation for surgery or treatment is to ask, "if this were your mother/father/wife...would this be the treatment you would recommend?"  At the very least it slows the process down and makes it a more thoughtful one.

 Mr. Sanit article from Tennis, Nov 2010

21 comments:

KM said...

This is a great post and one that is valuable to have had explained exactly the way you did for everyone to read. Thanks for writing this.

Kate said...

Well said. I couldn't agree more. My 93 year old dad was diagnosed with a large melanoma on his scalp earlier this year. He had a local, wide resection performed and healed up very well. Doc explained that he could do a lymph node dissection and scans of chest/abdomen to look for enlarged nodes, metastatic disease and my Dad fortunately said NO. I think the surgeon was relieved. He knew it would not be the best choice at his age. We are left with unknowns but that's OK.

CountryMidwife said...

I am wholly supportive of patients and families being advocates for their care and well being. But I also think we're letting doctors off the hook a little too easily. Primum non nocere seems to be forgotten too easily, too often in modern society, mostly because of defensive medicine, also (arguably) because of reimbursement issues. Certainly, doing something is more lucrative than doing nothing. Obviously the culture of physicians as moral compasses in society is lost, but I suspect most docs know they aren't being the physicians they dreamed of being. Is that an unfair burden placed on doctors? Perhaps, but if so, maybe the oath should be rethought.

Michael Kirsch, M.D. said...

Toni, I agree with 97% of this post. Currently, I am seeing a 98 yr old in the hospital (even older than Mr. Sanit!). She may have cholecystitis (sick gallbladder) in addition to some other ailments. After speaking with her son, initially, I advised antibiotics only. I am not certain that she truly has cholecystitis. Yesterday, the hospitalist decided to consult a surgeon. Is this the right call? I'm not judging here, but these are tough issues.

I would be cautious about using the 'what if the pt was your wife' technique as none of us can be objective with our close relatives, but, of course, I get your point. Kudos on the post.

Toni Brayer, MD said...

Michael Kirsch,MD: Thanks for the comment. The fact that the patient is 98 does make a difference. If he were 48, the surgeon intervening would be a no brainer "Lets just go in and see what we can do!" But he's 98. Can he get around? Does he have other serious conditions? Is he mentally intact? Does he have home support or would he be living in a hospital to recover? All of these things make a difference in the decision and it might be better to just wait and see if his body can turn things around with antibiotic support. If surgery is decided, that wouldn't be a wrong decision, but the whole picture is needed.

Paula Dhanda, MD said...

Thank you for a great post. I think about this every time I do surgery. Will this woman have better quality of life after surgery? Sometimes I recommend against surgery and if the patient or family disagree I help them to get another opinion. I don't know everything I just strive do my best everyday.

"Guppy" Honaker said...

My primary care doctor knew I had skin cancer - kept doing surgeries on me, and never once mentioned that I really should be going to a dermatologist. "Do no Harm" meant nothing to him - it was all for the money.

- David

Aloe Vera Juice Benefits
Holistic Nutrition and Health

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BrainDame said...

Great post-I really do agree with your thoughts but I would balance things a little by saying that with our aging population being more healthy overall, sometimes too many people get stuck on the concetp of "too old for surgery" when we know this is relative and constantly evolving with technology.
I love reading your blog!

Toni Brayer, MD said...

BrainDame: thanks for your thoughtful comment and back at ya!

PaulaDhanda: And a good job you do, too!

Guppy: Sorry you had that experience

"Guppy" Honaker said...

Thanks Dr. Brayer: I'm sure with you as my MD I would not have had that experience. The two kinds of skin cancer are now everywhere - just keeping fingers crossed that nothing shows up on vital organs.

I really, really, like this blog. Good to have this kind of information (such as your current posting on why she fainted) from a professional (who cares!).

BTW: "Guppy" is the name from my grandson who at the time couldn't pronounce "Grampy." Now all the kids at church (Mormons - so lots of them) and on our block here in Phoenix call me that. As does my now 3 years old granddaughter (my grandson is now 5 and in Kindergarten - I can hardly believe it). Best regards,

- David

Aloe Vera Juice Benefits
Holistic Nutrition and Health

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