Thursday, October 16, 2014

On Being Mortal

A review by Community Ethics Committee member Kathy Kaditz of On Being Mortalthe important (and, hopefully, influential) new book by surgeon and journalist Atul Gawande:

I finished Atul Gawande's new book, On Being Mortal. It is a quick read, several of the case studies have been New Yorker articles. However, I think it is absolutely brilliant. In very plain language accessible to most, he makes an incredible case for end of life conversations, techniques to make them helpful for patients and families, and the need to stop doing "everything medicine can do" as the default, at the end of life. He addresses death with dignity laws, the need for palliative care and hospice, the uncertainty patients and doctors experience when they cannot fix what is broken. He addresses it all in a historical and cross cultural context. I think we should all read it. It suggests a clear path forward but one that will take time and effort to implement.

Monday, September 29, 2014

Failures of end of life healthcare redux

It's not news that end of life care is broken.  A recap from current discussions; Zeke Emmanuel (yes the brother of Rahm, formerly seen around the White House and presently holding offices in Chicago), and others.

Every now and then, it is instructive to see what physicians choose for themselves, in end of life health care.  See, and their obvious rejection of continued treatment in situations where the benefits are hard to identify, other than keeping the body alive.
----------from the article-------
A chart of doctor responses from the Precursors Study:
Preferences of physician-participants for treatment given a scenario of irreversible brain injury without terminal illness. Percentage of physicians shown on the vertical axis. For cardiopulmonary resuscitation (CPR), surgery, and invasive diagnostic testing, no choice for a trial of treatment was given. Data from the Johns Hopkins Precursors Study, 1998. Courtesy of Joseph Gallo, "Life-Sustaining Treatments: What Do Physicians Want and Do They Express Their Wishes to Others?"

Thursday, September 25, 2014

Back to basics

This blog is about medical ethics, I understand that.  But sometimes it's useful to stand back and examine the assumptions of what constitutes "ethics" and "moral behavior."  Most of us would, I believe, consider moral and ethical decisions the domain of people rather than machines, but as computers and software that run on them become ever more powerful, some developments are worth keeping an eye on: autonomous machines that are expected to make moral / ethical decisions. 

$7.5 million is a drop in the very large bucket that could make such a scenario possible, yet the very existence of the bucket should wake us up and think about, and sort out in our heads, what is "right" and "moral" and "ethical."

There have been many and complex arguments taking positions at extremes such as "of course computers will be sentient (and soon!)" to "machines can never achieve awareness that humans do," and every slice in between.

If you have already thought about what you mean by these words, excellent. If not, now's a good time to wrap one's head around this nontrivial topic.  Can an autonomous robot make moral decisions?    Public policy on it depends on thoughtful input.

Wednesday, August 6, 2014

People First, Disability Second

Medicine does not need more cryptic language. And so upon discovering PFL, I did not celebrate the arrival of a new acronym in the world of health-care communication.

What PFL stands for, on the other hand, we should all celebrate.

PFL is short for People First Language, a movement to promote dignity and inclusion for people with disabilities. And unless you’re a headline writer with space limitations, there is no good reason to shorten it. So, Delaware legislators, lose the acronym. But keep the concept. By all means, keep that going forward.

I learned about Delaware House Bill 416 from legal scholar Thaddeus Pope’s blog.

“The legislation creates no new rights or duties,” Pope writes. “But like new legislation in many other states, it improves the vocabulary and terminology in existing law relating to people with disabilities.” 

Some changes are fairly subtle: from “the disabled” to “persons with disability.” Others replace insensitivity with respect: Gone is the term “mental retardation,” in favor of “intellectual disability.” The purpose is to promote dignity and inclusion. You’ll find a chart with more People First examples on Pope’s blog.

“This language emphasizes that individuals are people first, and that their disabilities are secondary,” according to a summary of the bill.

Understanding and clarifying language was pivotal to the Harvard Community Ethics Committee’s recent study of recipient selection criteria for pediatric organ transplantation.

The CEC wrote: “Neurodevelopmental disability, intellectual disorders, and related terms may hold clear meaning for medical professionals and, more particularly, within a transplant center, but they do not seem to mean the same thing from center to center, and certainly they held no consistent or clear meaning among the members of the Community Ethics Committee.”

For patients and families, simply understanding what’s going on in a medical crisis is challenging enough. When consent is needed, obtuse, legalistic and cryptic language can render “informed” consent an absurdity. But so often that is the very language of consent forms.

The forms tend to be written by lawyers, and “lawyers are not good at plain language. We’re good at protecting our clients, but lawyers don’t think about patients understanding.” That from Chris Trudeau of Michigan-based Thomas M. Cooley Law School, in his presentation at the Institute of Medicine’s recent workshop on health literacy and informed consent.

So the Patient First movement’s attention to language is worthwhile -- and not simply for people with disabilities. The World Health Organization has found that even in translation, the world “intellectual” is better understood by more of the public than are “neurological” or “cognitive.” In its report on pediatric organ transplantation, the CEC embraced the term “intellectual developmental disorder” over alternatives for its potential for achieving understanding and engendering trust in the organ transplantation process.

As the World Health Organization said in a 2002 report: “Every human being can experience a decrement in health and thereby experience some disability. This is not something that happens to only a minority of humanity.”

Saturday, August 2, 2014

Understanding Tuskegee's Legacy (Part 1)

First of two parts.

Four decades after the Tuskegee experiments ended, during a workshop on health literacy and informed consent, Dr. Alicia Fernandez of UC San Francisco said something remarkable and even chilling.

“That story,” she said of the infamous research, “most of my (medical) residents don’t know it.

“I guess they didn’t read the paper that day,” she added in disbelief. “But my patients know it.”

At Tuskegee, the subjects knew neither the title of the research (“Tuskegee Study of Untreated Syphilis in the Negro Male”) nor that they’d even been diagnosed with syphilis. When penicillin was found effective for syphilis, they continued to be studied but not treated with it. They suffered, infected others, and many died. This went on for 40 years, with government support.

The research began at the time Nazi doctors were engaged in the infamous work that resulted in the Nuremberg Code. But Tuskegee is in America, and the research continued long past the Nuremberg verdicts. (Good sources for learning about Tuskegee are here and here.) 

Though the men apparently participated willingly, they were lied to about what they were participants in. And so it was fitting that the workshop at the Institute of Medicine in Washington, D.C., coincided with the anniversary of Tuskegee’s end, on July 29, 1972. Tuskegee holds valuable lessons in health literacy, informed consent and the importance of understanding how they relate.

There is no overstating Tuskegee’s legacy of distrust in medicine. Of the major principles of medical ethics -- respect for persons, or autonomy; do no harm; do good; and justice -- Tuskegee betrayed all four.

Disparities in research and treatment are hot policy topics in medicine, and new doctors should understand their inheritance of patient distrust. Dr. Fernandez’s revelation indicates that short memory is another legacy of Tuskegee.

While the D.C. workshop took place, a group of physicians, scientists and interested others participated in a Twitter dialogue about Tuskegee. The events were unrelated, and yet many of the issues raised during the former, including low participation in research among blacks, were addressed in the latter.

“Even growing up my parents told me about this,” one participant tweeted. “Many blacks know of it and fear any ‘research’ about them.”

The TweetChat was organized around the hashtag #NSTNSchat. The acronym stands for National Science & Technology News Service, devoted to inspiring academic and professional interest among African-Americans in science, technology, engineering and math, or STEM for short.

“Are African-Americans still afraid of being exploited by science?” #NSTNSchat participants were asked. The answer is yes, but there is much more to it, and the dialogue was rich with insights into the role and importance of bioethics, strategies for affectively addressing health disparities and distrust, and the need for more African-American STEM specialists. 

Key players behind the dialogue were Dr. Caleph Wilson of the University of Pennsylvania, Princeton sociologist and author Ruha Benjamin and Dr. A. Breland-Noble of Georgetown. So engaged was this TweetChat, with so many different voices, that it went well beyond its allotted time.

The #NSTNSchat transcript is long and has many threads. So I tried something different in writing about it. I captured many of the main tweets and edited them into story form. It is constructed of the actual tweets, mostly verbatim, with some editing mainly to spell out abbreviations and acronyms, add punctuation and subtract redundancy. Context might change some from the original dialogue, and the tweets are presented as one voice, not multiple authors. 

The composite story appears in the blog post below. The original Tweets, and their authors, can be found on the Storify transcript.

For more about the National Science & Technology News Service, visit the website, and follow  @TheDarkSci on Twitter.

Understanding Tuskegee's Legacy (Part 2)

Second of two parts. This story is constructed entirely from Tweets in a chat organized by National Science & Technology News Service. See the original transcript here 

To understand the Tuskegee study, you have to understand it within the context of racism. The US apologized for the Tuskegee Syphilis Experiment, led by the US Public Health Service on rural African American men, 65 years after it occurred. President Clinton apologized for the government’s involvement. But was that enough?

Tuskegee plays a role in minimal participation of blacks in clinical trials. The impact of the syphilis study can be seen today in huge health disparity gaps. Lingering mistrust of clinical research is real and valid even for those of us in the industry.

It matters because it still impacts why so few clinical trials include African-Americans and other people of color. Mistrust of medicine leads to many people not asking questions of doctors about their care and to low medicine adherence.

Tuskegee should make us wary about all invocations of research for “the greater good” -- great and good for whom? Who decides?

Consider that many people are still afraid to ask their own doctors demanding or insisting questions. Minorities and vulnerable people need to ask more questions. Easier said than done  with underlying fear and mistrust. 

Fear is a byproduct of powerlessness. So you don't treat "black mistrust" simply with more information, but with empowerment. Trust-building is not a function of giving people facts. I wish public health researchers understood this. We need more minorities and people of color in the feeder disciplines that lead to folks going into bioethics.

We should be at community health fairs and screenings, libraries, blood drives, etc. True community participation in research requires sharing power and benefits from research. I've heard researchers say they don't know where to find patients to include. If you don't look for us, we can’t be there.

I wonder about how much the men and their families actually trusted the senior officials and just deferred instead. The men were denied treatment for their disease for many, many years even after treatments became available.

Informed consent means nothing if you don't understand the implications. The main reason I hear when people give consent: "Maybe this will help my kids, grandkids, etc."

Are there structural barriers preventing minority patients from increasing research participation? I think that, as much as a lack of diversity, it is a lack of cultural awareness on the part of the researchers. Non-minority researchers need to educate themselves and then advocate for peers to be better.

Mistrust + lacking public health outreach = research gaps.

Discussions need to be proactive. It shouldn't be relegated to Black History Month at our institutions. Educate ourselves as to what questions to ask researchers and insist those questions are answered to their satisfaction.

What is mistrust turning us into? Perhaps we should invest more in treating ailing social order: inequality makes us all sick.

Community-based participatory research is so important. Partnering with communities helps build trust. Work WITH people of color, and not ON, and trust will be built. 

Let’s reframe mistrust -- not as an OBSTACLE to overcome, but as a set of INSIGHTS into flaws of the medical and social system. “Cultural mistrust” can be protective, even healthy and appropriate. Patients know when to trust. They can feel it.

Science is not an inherently noble value or cause. Applying bioethics allows what we do to be noble. Without justice at center, bioethical principles can be used to legitimate unjust practices. IMO, too often people rely on "but the IRB said it's OK." Institutional Review Boards are human, too.

I'd like to think that we've learned to be more ethical in research as a result of Tuskegee. Prison studies say otherwise. Applying bioethics is key. Deadlines, timelines, dollars & powers that be will always exist. Bioethics keep us honest.

Bioethics 101: these are *real* people with *real* lives, not petri dishes and control agents. 

As we discuss importance of research, remember importance of developing relationships with and within communities  Too many scientific "centers of excellence" and not enough community engagement -- also part of the trust problem.

The original sin of Tuskegee was the devaluation of black humanity.

I've learned there’s too much emphasis on "black distrust" as cultural pathology: W.E.B. DuBois: "How does it feel to be a problem?" 

Saying "black distrust" makes it sound like there's no issue with institutional trustworthiness. We need to place more emphasis on trustworthiness of our institutions. "Black distrust" diverts attention. 

I've also learned that African-Americans can teach researchers a lot about how to do our work, if we just ask. We need a scientifically literate population. It's a public health issue!

The problem was devaluation of black humanity, which helps explain so much in our community. We need to get past Tuskegee and expand the conversation of minorities and ethics.

This is why diversity of the research workforce is so key. We must have diverse investigators to inform equity.

We have a long and winding road ahead of us, and African-Americans have legitimate concerns re: research. Listen to community. Don’t make assumptions. Ask questions before acting. The solution isn't to cure cultural pathology, It's to end racism in research.

We can never give up on our quest to stay in the biomedical science enterprise. There is strength in diversity.

Institutions need to show actual steps they've taken and are taking to protect patients; no ambiguous bullet points. Healthy skepticism is good. Keep asking questions. Refuse to be ignored. Be your own advocate.

Biomedical research industry has to be more of an advocate in all socio-economic realms that impact health disparities. What more should the biomedical research community do to earn the trust of people of color? Shut up and listen.

Do you believe lack of diversity in science researchers makes a difference in building trust?

Can I *like* that question about a billion times!?

For more about the National Science & Technology News Service, visit the website, and follow  @TheDarkSci on Twitter.

Tuesday, July 29, 2014

Lighting a Fireball Under Informed Consent

The experts and their PowerPoints gathered in the nation’s capital. The purpose was to advance an important effort by the Institute of Medicine to improve communication and understanding between doctors and patients and researchers and subjects. No simple task, this.

Best practices were discussed, and one received special attention. Alas, amid the downpour of information during Monday’s daylong webcast of the Institute of Medicine’s workshop on informed consent and health literacy, I seem to have missed this most important of best practices.

I did hear that this particular best practice “increased comprehension better than the other modalities.”

And perhaps that’s why I missed it. I don’t speak in modalities, and that phrase highlighted for me the potholed intersection of informed consent and health literacy. Further complicated by language barriers, informed consent becomes a foreign concept in a time one presenter called “the wild west of data.”

The Institute of Medicine workshop was impressive, informative, perhaps even visionary, and concluded with a call from Dr. Michael Paasche-Orlow, professor of medicine at Boston University, not for simple tweaks but for a course change in scientific and medical culture -- “from persuasion to pedagogy.” (There’s one of those words again; I believe he meant a change from pleading to teaching.)

In particular, this course change demands attention to improved communication skills, so that when a doctor like Jeremy Sugarman of Johns Hopkins tells his patient she has “fibroids in the uterus,” and she hears “fireballs in the uterus,” he’ll know it and correct it.

Overcoming such language barriers, said Dr. Alicia Fernandez of UC San Francisco, “will improve informed consent for all patients.”

According to Fernandez, 21 percent of Americans speak a language other than English at home, and she cited a University of Washington study in presenting a troubling snapshot of medicine as practiced through interpreters. More hopefully, she said, when physicians are bilingual, “communication is more likely to be patient-centered.” 

Sugarman cited his patient’s “fireballs in the uterus” to humorous effect. Another patient heard him describe the “insensitive care unit,” and a diagnosis once was quoted back to him as “sick-as-hell anemia.”

But a malaprop is only a problem if the doctor doesn’t know he or she has been misunderstood. If the doctor knows, a discussion and better understanding might follow. And even, perhaps, truly informed consent.

Even among scientists and medical professionals, the obligations and purposes of informed consent are not universally clear, in part because they are not always the same. Consent is better understood as a process than a form, and it differs greatly for a patient than for a research participant (for whom there may be no expected benefit from what is being consented to). And consent forms are full of legalese.

“I have a lot of problem with the writing (in consent forms),” said Chris Trudeau of the Michigan-based Thomas M. Cooley Law School, whose PowerPoint included the before and after of a consent document. It was indecipherable in its original form, significantly more accessible following his surgical removal of polyps and the like. “Lawyers are not good at plain language. We’re good at protecting our clients, but lawyers don’t think about patients understanding.” 

The workshop itself neglected patients. Notably missing were patient and community perspectives, but to the credit of the members of the roundtable, and their chair, Dr. George Isham, they won’t long be absent from this process.

“What I see missing in this room are patients,” said Dr. Kenneth Saag of University of Alabama-Birmingham, “and people with a high school education or less, and there’s not as much diversity here as we’re dealing with.”

Sandra Crouse Quinn, a professor at the University of Maryland, noted that institution’s effort to address low participation in research by people of color via the program Building Trust Between Minorities and Researchers. “Minorities increasingly are willing to participate in research,” she said, “but they’re not participating.”

“A lot of us are too close to these issues,” Isham said toward the workshop’s end, “and don’t see the forest for the trees.”

With patient and community perspectives, the focus might improve.

See more about the workshop here

Wednesday, July 16, 2014

A Stethoscope for the Soul

The book title was familiar: “The Soul of Medicine.”

Sherwin Nuland, the influential surgeon, bioethicist and author, who died this spring, gave that name to his 2009 collection of stories, subtitled “Tales from the Bedside.”

The title is thoughtfully provocative. Does medicine have a soul? Do people? And what happens in the doctor-patient relationship when one answers yes and the other no? As I said, the title is thoughtfully provocative.

And here it comes again. “The Soul of Medicine”  (Johns Hopkins University Press) is also the title of a 2011 collection of stories co-edited by John R. Peteet and Michael N. D’Ambra and used as the text for “Spirituality and Healing in Medicine,” the course they teach at Harvard Medical School.

Two books with the same title is a little confusing, but it’s a healthy confusion. Especially if Peteet, D’Ambra and spirituality-minded colleagues are correct about “widespread concern that medicine may be losing its soul.”

“Prominent scientific critics such as Richard Dawkins have painted religion as an inherently biased phenomenon defined by irrationality, and anything associated with it as the antithesis of scientific progress,” writes Marta Herschkopf, a Harvard-trained physician, Yale- and Oxford-trained theologian and contributor to “The Soul of Medicine.” 

“No doubt influenced by such rhetoric, many physicians and administrators feel that spirituality has no place in a medical curriculum or in medical practice. Despite a significant body of research arguing to the contrary, they do not see religion and spirituality as directly contributing to human health and therefore consider it irrelevant.” 

I was reading Peteet and D’Ambra’s book as a three-day course in bioethics began at Harvard Medical School, which I attended as a member of the Harvard Community Ethics Committee.

Neither Peteet nor D’Ambra are faculty for the bioethics course, and their book was not cited. And yet theirs was the text I thought of during a break. A chaplain who had asked several probing questions during a session wondered if she had asked too many. She hadn’t, I assured her. Indeed, I welcomed the questions. They were insightful and brought a wondering and spiritual component into the dialogue.

Ethical conflicts in medicine, at least the ones I’ve studied as a member of the Community Ethics Committee, seem to sprout from communication problems and a disconnect between medical expertise and patient values. Since the doctor-patient relationship would be where “medicine may be losing its soul,” understanding and engaging those values is important.

Peteet and D’Ambra edited the collection, wrote the preface, and collaborated on chapters with theologian and palliative care expert Michael Balboni and psychologist, ethicist and rabbi Terry Bard. For other chapters, they brought together medical professionals and others with expertise on Judaism, Hinduism, Islam, Christianity, Buddhism, Eclectic Spirituality, Christian Science Jehovah’s Witnesses, A Secular Perspective and a historic context for this complex subject.

According to internist and ethicist Thomas Huddle, quoted in the chapter Ethical Considerations and Implications for Professionalism: “In asking for professionalism, that is, for just, altruistic, conscientious and compassionate physicians and trainees, medical educators are asking for morality, which is at bottom asking for more than expertise.”

Gowri Anandarajah, a family practice physician affiliated with Brown University, turns to Gandhi for insight into Hindu perspectives on medicine: “God does not come down in person to relieve suffering. He works through human agency. Therefore, a prayer to God, to enable one to relieve the suffering of others, must mean a longing and readiness on one’s part to labor for it.”

Perspectives in “The Soul of Medicine” can be contradictory, but such is the nature of the various faiths and spirituality. 

Dr. David Ring of Massachusetts General Hospital helps explain why science and religion/spirituality are such an uneasy pairing.

Ring writes: “The medical facts established by scientific experimentation are not typically disputed among various faiths and traditions. The realm of spirituality in medicine begins at the limits of science, at least when operating in the biomedical model of illness.”

Later, he adds: “Faith -- believing that one knows or understands something in the absence of sufficient experimental evidence -- is often counterproductive. Faith in the sense of optimal ‘spiritual’ health, on the other hand, is an integral part of wellness in a way that is measurable by experiment.”

Through studies of end-of-life care and treating human suffering, the Community Ethics Committee, which hosts this blog, repeatedly considers whether and where spirituality and religious faith belong in the contemporary dialogue about care.

Committee members past and present include include a rabbi, an imam, atheists, a Catholic chaplain, a Methodist minister, a professor at a Christian college and a Unitarian. With such a range of perspectives and values, clarity of language and meaning become crucial, says co-founder Carol Powers.

The Community Ethics Committee’s top priority is “the patient in the bed,” Powers has said often. But what of those with the daunting challenge of diagnosing and explaining medical problems, and helping patients come to decisions that respect both personal values and what is medically possible?

According to “The Soul of Medicine: “Because the behavior of physicians is largely self-regulated, encouraging them to seek as many resources as possible, including spiritual ones, will, one hopes, increase their ability not only to continue to strive to be professional, but also to find more lifelong career satisfaction.”

This post also appears at

Wednesday, June 25, 2014

A Ration of Hope

A year ago, a Pennsylvania child expected to die without a lung transplant received the needed organ through the tireless advocacy of her parents, and media campaigns, the intervention of clergy and politicians and a judge’s ruling.

That she is alive today is an extraordinary and heart-warming story of the medically miraculous, one recounted by CNN and NBC News, and the child’s case now has prompted a policy change ending discrimination against children as candidates for adult lungs. Not that it will end discrimination; amid organ scarcity, that isn’t possible. Deserving people die every day awaiting new organs.

Harvard’s Community Ethics Committee recently completed a study of criteria for listing potential pediatric transplant recipients. That process left me with a new appreciation for distributive justice and rationing amid organ scarcity, the competing demands for privacy and decision-making transparency, and respect for clinicians who must determine who is sick enough to need a new organ but otherwise healthy enough to make transplantation successful.

The policy change was among several announced Monday by the board of directors of both the United Network for Organ Sharing and the Organ Procurement and Transplantation Network. The board “approved on a permanent basis a policy change allowing transplant programs to request additional, exceptional priority for adolescent or adult donor lung offers for transplant candidates age 11 or younger. The action followed additional review of a temporary exception adopted in 2013.”

As of Tuesday morning, there were 78,811 active candidates on the waiting list for organs, according to OPTN. How many of them will receive organs is unclear, but most will die waiting. From January through March of this year, 6,978 patients were transplanted with new organs. 

There are a few things that the CNN and NBC stories didn’t tell me:

Who died so that the Pennsylvania child might live? By my estimation, four people died. Two were the lung donors. When the first transplant failed, the child received another.

The other two people died on the same organ waiting list that the child moved to the top of. Lungs were not available to them, because the child received them. This is the norm in transplantation; many more die waiting than ever get to transplant. The court did not consider this in its ruling.

How many people who signed the petition in support of the child have subsequently signed up as organ donors? If it’s anything like the general public, the percentage is small. Many more say they support organ transplantation than actually “opt in” as potential donors. 

Is it simply that transplant policy was wrong, and children make good candidates for surgically modified adult lungs? Or do adult lung diminish chances of success when transplanted into a child?

Would an “opt out” policy work in the United States? That is, could organ donation be assumed unless a person specifically opted out of the system -- as is the case in several countries?

How is it that CNN and NBC News could report this story without mention of rationing or distributive justice? Americans tend to support the life-saving nature of organ transplantation, but oppose rationing. And we can’t have it both ways.

Sunday, June 22, 2014

Emotion, Reason & the Ethics Consult

Over the coming weeks, I hope to share key take-aways from the Harvard Center for Bioethics’ three-day course in clinical bioethics. 

Here’s a start. At Massachusetts General Hospital, Guy Maytal holds these titles: associate director of ambulatory psychiatry, director of primary and urgent care psychiatry, and psychiatric liaison to palliative care. He also is involved in ethics consults.

You wear that many hats, there is bound to be confusion: So it’s not unusual for him to be called for a psych consult on what is essentially an ethics matter, or for an ethics consult on a psych matter. The lines blur. Maytal once received a call for a consult “because the patient cried.” Which says more about a clinician’s inability to sit with emotion than with any problem on the patient’s part.

Maytal’s lecture at the Harvard bioethics course focused on reason and emotion in clinical ethics and included this useful insight: “In the brain, there is no division (between reason and emotion); there’s a balancing act.” 

Maytal is a masterful lecturer. Here are his essential tools for an ethicist in a consult:

  • Bring awareness to your reactions
  • The role is the target, not the individual
  • It's not personal
  • What do I make it mean?
  • Patients come not with problems, but with solutions that no longer work
The patient perspective in that last one puts into context how a clinician might confuse psychology and ethics consults. The lines blur, indeed.

Tuesday, May 13, 2014

Use of Video in End of Life Decision-Making: a Concern

Videos have come to be regarded by many as a valuable aid in helping patients make decisions about their care when such videos supplement a conversation with a physician that explains possible treatment options. A number of research studies (here, here and here) suggest that such use of videos can lead to more informed patients and, for patients approaching the end of life, a greater likelihood of patients opting for comfort care rather than life prolonging treatments.

I would like to express one source of unease with the use of video in this context and identify a possible weakness in the associated empirical studies.

Several studies feature a patient factual assessment, a set of multiple choice and true/false questions about relevant medical care. Those who watch the videos and receive a verbal explanation of treatment options generally score better on this assessment than the control group, who receive only the ordinary verbal explanation. The authors of the studies conclude from the assessment scores that the video group are more informed about the relevant treatment options, and naturally infer that this group’s greater preference for comfort care over life prolonging care is to be accounted for in terms of their being more informed than the control group. This offers a positive outlook for the place of video in supplementing the physician’s verbal explanation as a means for patient education and empowerment:

When faced with the possibility of their cancer progressing, participants with malignant glioma who viewed a video of the various goals-of-care options in addition to listening to a verbal description were more likely to prefer comfort measures and avoid CPR, were more knowledgeable regarding the subject matter, and were more certain of their decision when compared to patients only hearing a verbal narrative. (“Use of Video to Facilitate End-of-Life Discussions With Patients With Cancer: A Randomized Controlled Trial”)

An alternative interpretation of the evidence is possible, however. Might not the participants be having an emotional reaction to the video, and might it not be this emotional reaction, not their being more informed, that is causing their comfort care preference? And might not the video group’s generally remembering more information about medical care, as demonstrated in the multiple choice and true/false assessment, also be caused by their emotional reactions to the video? On this reading, it is an emotional reaction to the videos, not their educational effect, that is causing both phenomena identified by the studies - the higher assessment scores and the preference for comfort care. If this were so, a reevaluation of the role of video in informing patients would appear in order.

In order to forestall this kind of objection, the authors of one study note that “Participants' comfort level with the video is … reassuring against this possibility [of an emotional reaction’s causing the treatment preference].” One might also question whether an emotional reaction can improve scores on a factual recall assessment. How could that be?

I would note, however, that self reported levels of comfort are an unreliable guide to a person’s emotional state, even under normal circumstances, and there is empirical literature suggesting that emotional reactions may indeed lead to more accurate retention of information, a phenomenon that might better explain the video watchers’ scoring better on the factual assessment. It is well known in the field of advertising that coupling a visual emotional trigger with factual information can greatly enhance future recall of that information. This is not a promising analogue for doctor patient communication about end of life care options.

The authors of the first video study referenced above concede that “an emotional response to the video could have influenced participants’ preferences,” and immediately follow with “To ensure that the video was not biased toward any particular perspective, the video content underwent extensive scrutiny by numerous oncologists, intensivists, palliative care physicians, and ethicists with particular expertise in this field.” But the problem is that scrupulously guarding against bias in a video does nothing to address the possibility that an emotional response is influencing participants’ preferences.

Perhaps the authors’ point is that an accurate video that may indeed provoke an emotional reaction nonetheless has educational value when viewed with a physician in the context of a discussion about treatment options. What can be wrong with seeing for oneself the unbiased reality of each option, even if this elicits an emotional reaction?

This may be the crux of the issue. One difficulty is that video images, however deliberately produced and contextualized, and however true to the patient’s prognosis, have a power to subvert other, more subtle imaginative resources that we draw from in making informed personal choices. The professional lens through which a physician views and interprets an image of a patient receiving treatment is utterly different from that which shapes a patient’s apprehension of the same image. By contrast, with the standard model of doctor-patient communication, a skilled physician can determine her patient’s reception of her explanation of treatment options and take account of this reaction in guiding conversation. The reading of emotional cues and the making of adjustments may not be possible with a video as part of the interaction, giving less assurance that patient reactions are understood, acknowledged, and balanced. The role of emotions in patient decision-making is so complex, and the content of the videos (I’ve seen them) powerful enough that a shift in patient preferences of the kind observed in these studies should give us pause.

While all acknowledge that aids to genuinely informed end of life decision making are increasingly necessary, perhaps the jury ought still to be out regarding the role of video in this context.