Medicine In America

This article, while on the surface seems benign in its approach and suggestions, is infuriating and offensive to myself, a physician who specializes in critical care medicine. While I would normally hesitate to generalize and doubt how a hospice nurse has the clinical experience to propose such trite recommendations, her essay opens herself to sharp criticism. Ms Brown’s descriptions of physicians as those “who look at patients primarily as collections of individual problems, rather than very sick individuals” is disappointing because it is so lazy and unsophisticated. If this isn’t insulting enough, her next paragraph is a veiled allegation that physicians are keeping dying patients alive for financial gain. Oh, but her wisdom on this subject is so great that she is able to understand the source of problems she was not even witness to. A patient’s family told her they didn’t appreciate how ill their loved one was, so of course Ms Brown knows it was the callous physicians and nurses too busy to care, that the staff ‘didn’t have time, or wasn’t able to make time’. Any medical student on their first clinical rotation quickly learns how little patients and families retain from clinical discussions, especially in an end of life situation as Ms Brown describes. Her ignorance of this makes me doubt what experience she truly has. Any doctor or nurse who has spent any time in an ICU is familiar with the patient or family who, despite repeated careful discussions, still can not grasp the totality of crushing illness and the prospect of death. In addition to being ignorant of this common occurence, Ms Brown is apparently uninformed about the typical discrepancy of prognostic outlook between physicians and families. True to my experience, it is the physicians and nurses who often project a realistic outlook for a patients clinical course, while the family understandably, for many reasons, will cling to an unreasonably positive prognosis (see JAMA. 2016;315(19):2086-2094. doi:10.1001/jama.2016.5351) . But let us not let reality and evidence get in the way of another pointless care algorithm that reduces nuanced medical care to flow charts, arrows and colored boxes. But of course real descriptions of the good care provided in ICUs is not as provocative as describing greedy doctors grinning at the bedside of dying patients, deaf to their patients suffering cries. It is baseless articles like this that can perpetuate doubt in the well meaning doctors and nurses who labor at the bedside of critically ill patients, some who will live and some who will die. Shame on you Ms Brown.