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Saturday, December 24, 2005

Doctors' Delicate Balance in Keeping Hope Alive - New York Times: "The language of hope - whether, when and how to invoke it - has become an excruciatingly difficult issue in the modern relationship between doctor and patient.
For centuries, doctors followed Hippocrates' injunction to hold out hope to patients, even when it meant withholding the truth. But that canon has been blasted apart by modern patients' demands for honesty and more involvement in their care. Now, patients may be told more than they need or want to know. Yet they still also need and want hope.
In response, some doctors are beginning to think about hope in new ways. In certain cases, that means tempering a too-bleak prognosis. In others, it means resisting the allure of cutting-edge treatments with questionable benefits.
Already vulnerable when they learn they have a life-threatening disease or chronic illness, patients can feel bewildered, trapped between reality and possibility. They, as well as doctors, are discovering that in the modern medical world, hope itself cannot be monolithic. It can be defined in many ways, depending on the patient's medical condition and station in life. A dying woman can find hope by selecting wedding gifts for her toddlers. An infertile couple moves on toward adoption.
The power of a doctor's pronouncements is profound. When a doctor takes a blunt-is-best approach, enumerating side effects and dim statistics, in essence offering a hopeless prognosis, patients experience despair."

Candid exchanges about diagnosis and prognosis, especially when the answers are grim, are a relatively recent phenomenon. Hippocrates taught that physicians should "comfort with solicitude and attention, revealing nothing of the patient's present or future condition." A dose of reality, doctors believed, could poison a patient's hope, the will to live.

Until the 1960's, that approach was largely embraced by physicians. Dr. Eric Cassell, who lectured about hope in November to doctors in the Boston area, recalled the days when a woman would wake from surgery, asking if she had cancer:

" 'No,' we'd say, 'you had suspicious cells so we took the breast, so you wouldn't get cancer.' We were all liars." Treatments were very limited. "Now when we're truthful," Dr. Cassell added, "it's in an era in which we believe we can do something."

Doctors in many third world countries and modernized nations, including Italy and Japan, still believe in withholding a bad prognosis. But the United States, Britain and other countries were revolutionized in the late 60's by the patients' rights movement, which established that patients had a legal right to be fully informed about their medical condition and treatment options.

Now, whether a patient comes in complaining of a backache, a rash or a lump in the armpit, many doctors interpret informed consent as the obligation to rattle off all possibilities, from best-case to worst-case situations. Honesty is imperative. But what benefit is served by Dr. Dour?

"There are doctors who paint a bleaker picture than necessary so they can turn out to be heroes if things turn out well," said Dr. David Spiegel, a psychiatrist at Stanford medical school, "and it also relieves doctors of responsibility if bad things happen."

The fear of malpractice litigation after a bad outcome, he said,

Hope," wrote Emily Dickinson, "is the thing with feathers/That perches in the soul."

Imprecise and evanescent, hope is almost universally considered essential to the business of being human.

Few can define hope: Self-delusion? Optimism? Expectation? Faith?

And that, say experts from across a wide spectrum, is the point: hope means different things to different people. When someone's medical condition changes, that person's definition of hope changes. A hope for a cure can morph into a hope that a relationship can be mended. Or that one's organs will be eligible for donation.

For so many, hope and faith are inextricably linked. "Truly spiritual people are amazing, " said Ms. Murphy of University Hospital. "Until the moment of death, families pray for a mira

The fear of malpractice litigation after a bad outcome, he said, also drives doctors to be stunningly explicit from the outset.

The medical community has nicknames for this bluntness: truth-dumping, terminal candor, hanging crepe. But some social workers call it false hopelessness.

Given a time-tied prognosis, many patients become withdrawn and depressed, said Roz Kleban, a supervising social worker with Memorial Sloan-Kettering Cancer Center. "Telling someone they have two years to live isn't useful knowledge," she said. "It's noise. Whether or not that prediction is true, they lose their ability to live well in the present."

Health care providers debate the wisdom of giving patients a precise prognosis: "There's an ethical obligation to tell people their prognosis," said Dr. Barron Lerner, an internist and bioethicist at Columbia University medical school, "but no reason to pound it into their heads."

Others say that doctors should make sure they can explain the numbers in context, with the pluses and minuses of treatment options, including the implications of choosing not to have treatment.

Though many patients ask how long they have to live, thinking that amid the chaos of bad news, a number offers something concrete, studies show that they do not understand statistical nuances and tend to misconstrue them. Moreover, though statistics may be indicative, they are inherently imperfect.

Many doctors prefer not to give a prognosis. And, studies show, their prognoses are often wrong, one way or the other.

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eureka, California, United States
As Popeye once said,"I ams what I am." But then again maybe I'm not