Sometimes the best course of action is no action - or, at least, stopping long enough to really think through what should be done. Many interns have been offered this pearl of wisdom from senior residents encouraging them to stop and think during moments of crisis. Stopping and doing nothing is especially important in caring for patients at the end of life. Assessing pain and symptoms, ensuring comfort, and providing support requires a good bit of "standing there" with patients and families. Yet "doing nothing" is deceptively difficult - think about how hard it is to stand in silence during lulls in conversation.
Physicians say to patients, "You can have chemotherapy, get radiation, or do nothing." In our "take charge, can do, never say die" culture, which reveres independence and grit, "nothing" can be seen as surrender, defeat, or lack of will. Other times, physicians ask patients and families if they want "everything" done (especially in conversations about attempted resuscitation). The unspoken opposite is often assumed to be "nothing" instead of "everything but attempted resuscitation."
Physicians, nurses, patients, and families can all benefit by understanding that each option represents something and that no option is truly "nothing." Pain and symptom management is valuable for preserving comfort and function. Reaching personal goals and completing unfinished business is intense work. Saying goodbye is terribly difficult. Patients, families, and health care professionals must learn that "standing there" may be the best thing to "do." Physicians and other health care workers must consider this when explaining treatment options, especially when these are not likely to offer any benefit while creating further burdens. Surely it would be better to say, "You can have chemotherapy, get radiation, or decide to focus on living life fully, for all the time you get."
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].