Metastatic lung cancer: a dreaded diagnosis with high symptom burden and universally fatal outcome.
For the patient we recently cared for alongside the hospitalist and oncologist, it also comes with inevitable readmissions. On the third such hospitalization over a period of 6 months, with the advent of adult respiratory distress syndrome, acute kidney injury, and pancytopenia (thought by oncology to be a new hematologic malignancy), our patient was clearly nearing the end of life.
Yet there we stood hearing the family talk of intubation, dialysis, and even future chemotherapy while the patient required daily infusions of platelets and red cells, experienced delirium, and was unable to wean off bilevel positive airway pressure. This family did not request escalation of treatments. The seemingly endless array of options under discussion were offered to them by well-intentioned, caring physicians.
Evidence-based practice (EBP) has been a driver for much of what we do. Can we say the opposite is equally true? Does EBP govern what we do not offer patients and families, with a similar conviction and frequency? If we are to be successful in reconstructing health care delivery to provide safe, comprehensive care that leaves no one behind, then tending to what is unwanted, unnecessary, and nonbeneficial is a vital part of the strategy.
We propose using the term evidence-based restraint (EBR) as a counterpart to evidence-based practice. Evidence of the harms of overdiagnosis and overtreatment is mounting—leading to efforts such as the Choosing Wisely campaign and the Affordable Care Act’s emphasis on comparative effectiveness research. Yet when faced with a dying patient, many physicians seem compelled to offer treatments that are nonbeneficial at best, demonstrably harmful at worst. Overtreatment is remunerated in multiple ways: financial, personal satisfaction, patient and family appreciation. The harms of overtreatment are not yet widely recognized by health care professionals or laypersons, particularly when erroneously viewed as potentially curative treatment.
One piece of EBR that is likely to be challenging for all is telling patients and families "no." Health care professionals don’t want to destroy hope even when redirecting hope is a necessity. Conflict is frequently avoided, amicability in provider-patient relationships is strongly desired, and always looming is the possibility of lawsuits should disagreements lead to outcomes that do not meet family expectations. However, if we do not support one another in saying "no," then the engine of change will stall. One example of where to begin is cardiopulmonary resuscitation status. In JAMA, the authors of an opinion piece titled, "Time to Revise the Approach to Determining Cardiopulmonary Resuscitation Status," challenge us by saying that it is "not only ethical, but also imperative, that CPR not be offered" to those deemed to receive no benefit from it (2011;307:917-8). Paths to compassionately resolve patient and family wishes that are misaligned with the evidence include changes in hospital policy, ethics consultation, and a multidisciplinary approach. Additionally, physicians will need training and support for engaging in difficult conversations.
There are brave and bold voices championing EBR and garnering more attention as it surfs the rising tide of the Affordable Care Act. While only 1.5 years old, "Bending the Cost Curve in Cancer Care," a Sounding Board piece from the New England Journal of Medicine by Dr. Thomas J. Smith and Dr. Bruce E. Hillner, is already considered a seminal work (2011; 364:2060-5.)
In their discussion of bending the cost curve in cancer care, they call for restraint in oncologists’ behavior, attitude, and practice that artfully not only curtails spending, but delivers more patient-centered care. Health care systems should be looking to realign incentives to reward oncologists for seeing these adjustments put into action. Similar thought processes around cardiology, critical care, neurology, and other disciplines are currently in development.
Evidence-based restraint will not win the day easily or quickly. With limited resources and a growing population, it is imperative that we seek to provide care that is cost effective and beneficial, and available to all.