By Dr. Howard Brody
Some problems get better over time. Some don’t.
An international team of nurses asked their colleagues in five countries — the United States, Israel, Ireland, Italy and Hong Kong — what they’d recommend for a hypothetical elderly patient transferred to the hospital from a nursing home, who was bleeding from the gut and was unlikely to survive.
They were also asked what they’d want for this patient if it were their father, or themselves.
Here’s how I interpret the responses. If most of the nurses indicated that they’d want the same care for themselves or their parents as for the average hospital patient, that means they think that the average patient currently gets reasonable, humane care.
If, on the other hand, there was a marked difference between those responses, that would suggest that the nurses are critical of the care given to the average patient.
We have to bear in mind that while the physician might only see the patient for five minutes a day, the nurse is presumably in much longer and more frequent contact. So even if physicians think they are giving the best care, it might be the nurse who realizes that the patient is suffering (or alternatively, is being neglected or abandoned).
Two things struck me about the results. The U.S. nurses had the greatest differences between what they would do for the average patient and what they would want for a parent or for themselves. The difference was in the direction of wishing for much less aggressive treatment.
The United States was also the international outlier in what the nurses suggested as care for the average patient — notably more aggressive than what the nurses suggested in the other four countries.
So I am led to suspect that what the nurses say they’d feel obliged to do for the average patient is what they in fact see being done, day in and day out, in their facilities.
This response seems unfortunate.
Back in the 1960s and 1970s, we first started hearing complaints that medicine’s newfound technological ability to hook patients up to tubes and machines was outstripping our compassion — that we were trying to keep people alive well beyond the point when they could truly benefit or appreciate any quality of life.
Ever since, we have been busily trying to find ways to remedy this problem. We encourage people to complete advance directives to record their earlier wishes about end-of-life care. We have created a major movement in hospice and palliative care that was nowhere in evidence in those early years. We teach ethics courses in both medical and nursing schools that stress the patient’s right to refuse unwanted treatments.
If I am right in interpreting this study’s findings, then U.S. nurses, much more often than nurses in the other nations, still believe that what their facilities do to the average patient who’s near the end of life is far different from what they’d want for themselves or for their loved ones. And the difference lies in doing too much high-tech stuff, not in throwing in the towel too quickly.
And that seems to suggest that after several decades, and even after many significant advances, we are not much closer to solving this problem than we ever were.
Dr. Howard Brody is director of the Institute for the Medical Human-ities, University of Texas Medical Branch.