Specific Signs And Symptoms

We’re fundamentally social creatures, and a major brain injury can change all that. For physicians, quality of life often is measured in the absence of specific signs and symptoms, but we all know there’s much more to be considered. Some of these metrics work and others don’t. Physicians should strongly reject scoring systems with cutoff values that determine whether a person makes the grade or not. They can do it because they know the individual well enough to understand what that person would have wanted, which should be the only motivation. Physicians generally understand that we lack expertise regarding normality and abnormality when it pertains to quality of life. And we should avoid judging the meaning of life or deciding when life is miserable. We’re very cautious about what we say in that regard, and rightly so. When dealing with quality of life, we do better when we have less respect for rules and more respect for principles. For generations, a physician’s words were accepted as final, correct and to be obeyed. However, we’re not infallible. As health care staff, we acknowledge that we usually know very little about the lives of the patients we treat.

All Or Nothing At All

Factors that contribute to quality of life. These principles have proved useful in addressing difficult medical cases. They’re at the heart of a proper relationship between patient and family. Neurosurgeons are perfectly justified in refusing to perform surgery on a patient who won’t benefit from it, even if the patient or family members insist on trying everything. What are neurosurgeons obligated to offer when families forcefully insist that everything be done? It’s a challenging question, and answering it is particularly difficult when time is of the essence and it’s not possible to have an independent expert do a comprehensive review. In this difficult spot, I think many surgeons respond by performing Hail Mary procedures. Honoring an individual’s autonomy requires the individual be fully capable of exercising it. Autonomy is closely linked to the ability to make a choice and to understand the condition and reasons for medical treatment. When an individual is comatose, autonomy is fully transferred to family members. They defer to their significant other or offspring. A major challenge to a patient’s autonomy occurs if members of the health care staff use coercion in the form of manipulative language. In the United States, a physician shouldn’t make a drastic change in an individual’s care without the patient’s or family’s consent.

The Power Of The Dream

In the rare instances in which it might be necessary to act, the reasons for doing so should be documented. The other extreme involves ignoring requests to reduce aggressiveness of care, despite a family signaling that they’ve had enough. It’s important that physicians adopt a relational and sharing approach, and remain free of favoritism. That’s different, however, from withholding treatment based on a patient’s prior behavior and lifestyle choices. Physicians aim to ration their time to balance the needs of each patient against other obligations, knowing that vulnerable members of the community must be protected, and discrimination, including presumed bias toward ethnically diverse populations, must be avoided. Health care staff must practice utilitarianism, maximizing overall benefit, and providing equal service and opportunity to every individual. Physicians must avoid stereotyping, and inadvertently making an inappropriate remark is completely out of order. A moralizing stance is neither useful nor appropriate when interacting with an individual who may have made questionable choices. Practicing justice means avoiding bias. In relationships, bias is an inclination for or against a certain group or individual. By reflecting critically on our judgments, we avoid acting on harmful prejudice. Bias, however, is everywhere, whether we recognize it or not.

The Greatest Discovery

With hindsight bias, we blame ourselves or others for not having anticipated certain outcomes, which might only be obvious now with the benefit of more knowledge. We also unfairly assume that other people share our experiences and have drawn the same conclusions. When a person is in a good mood, it’s only natural to overestimate the likelihood of positive outcomes. Conversely, when someone is feeling down, it’s more likely that he or she will expect negative outcomes. These personal emotions also drive irrational thinking. We as physicians need to guard against common biases. Part of our medical and nonmedical decorum is to practice ethics to the fullest by recognizing pitfalls, biases, and wrong choices and working them through. Of course! one might say. But achieving beneficence requires the ability to empathize with the feelings, thoughts and attitudes of another person. Some health care staff come by this naturally, and for others, it must be learned. Empathy makes us curious about hidden emotional concerns in others and enables us to see the reality as another person perceives it. Many physicians view the concept of beneficence as the principle of improving quality of life, but it also involves the obligation to use medical knowledge appropriately. The result of these advances is that patients can’t be forced to proceed with anything in medicine. Patient autonomy is closely linked to the ability to choose and understand the rationale and consequences for medical or surgical treatment. It’s essential that there’s no indication of coercion. The once universally accepted old tropes of doctor knows best, the fighting doctor and the doctor that never gives up no longer apply. Rather, we seek to avoid unnecessary treatments that carry very serious adverse effects and could cause additional harm. Families often ask why their loved one suddenly got worse when everything seemed to be heading in the right direction. Examples include undergoing multiple brain surgeries, or continually withdrawing and reinstituting a ventilator. Rather than being overt, harm to the patient may be subtle. It may result from endless, overly aggressive treatments and surgical interventions that cause families to run up large medical bills. Beyond the four pillars are many other ethical issues health care staff deal with on a routine basis. Messages from society often factor into this decision. The patient or family members decide who can and can’t be informed.