Seeing the Physician’s Oath in a Different Light

Opinion

On the day that I put on my white coat and took a Physician’s oath, I made a promise to dedicate my life to the service of humanity. I promised to not only provide physical relief to my future patients, but to also tend to their emotional, behavioral, and psychosocial needs. I promised to endeavor to care for the sick, the poor, the suffering, and especially those who are dying with a heart of kindness and compassion. But little did I know, I didn’t fully understand the practical manifestation of the Physician’s oath that I took at the beginning of medical school. I thought I knew what it meant to tend to the needs of my patients who were suffering, especially those who were on the brink of death, until I completed a short rotation on Palliative Care. I used to believe that a good physician was one who would vow to do everything in their power to save their patient’s life, whether this was possible or not. This is what is taught in medical school. Physicians are programmed to focus on curing, not taught how to care for those who can’t be saved. Prolonging lives is what physicians are trained to do best and the lesson of providing comfort care isn’t one that gets much attention during the years of our medical training.

After working with several terminally ill patients and witnessing first-hand the major drawbacks of modern medicine even when being done with great intentions, I had to spend some time re-examining everything that I had learned and believed for the past few years of my training. One of my patients was a young man hospitalized for a bowel obstruction due to metastatic gastric cancer with an extremely poor prognosis of weeks, if not days. He was J-tube and total parenteral nutrition (TPN) dependent for nutritional support and receiving frequent blood transfusions when his hemoglobin went below 7g/dL due to his slow ongoing malignancy associated GI bleeding. His peritoneal metastasis also caused him to suffer from severe malignant ascites requiring frequent paracentesis, compounded with painful lower extremity edema and scrotal swelling in the setting of anasarca secondary to malignancy-associated malnutrition. All my patient wanted was to be able to drink by mouth and have his pain controlled. While he remained on TPN since he could not eat by mouth, the Palliative Care physicians were the first ones to propose the idea of discontinuing TPN and lowering the hemoglobin requirement for transfusion as it was obvious the excess fluids were causing more discomfort in the way of ascites and edema. The discussion with both the primary team and the patient’s family was challenging because these suggestions were perceived as withdrawing life support and consequently hastening death. I understood the rationale behind limiting these things: they were causing more harm than benefit. But it can be uncomfortable to limit medical treatments because most physicians do not want to feel responsible for contributing to a patient’s death. Sometimes we walk a fine line of violating the first and foremost principle of medical ethics, which is “do no harm,” because our goal becomes treating numbers and diseases, instead of the person with those ailments. Is it possible that there comes a time when trying to prolong life is no longer an act of compassion and kindness? Is it possible that while trying to prolong life, we take away what makes that life worth living? Is it possible that by trying to do what we have been trained to do, we cause patients more pain and suffering and deprive them of joy and happiness during the final few days that they have left in this life?

After seeing many of my dying patients suffer from medical interventions that no longer bring them benefits, I promise to resist the urge to push for more treatment when they cause more harm, when machines can no longer fix the organs that have failed beyond repair, or when artificial nutrition no longer provides the sustenance that the patient needs. I will no longer strive to do everything in my power to prolong the dying process, because sometimes, doing less is more. Especially for the patients who are dying within the span of weeks if not days, it matters not how much medical treatment we provide, but how much compassion we share with our patients in their final days.

I now promise to use my medical knowledge to not only save lives, when able, but also to decide when to stop saving lives. Though I will continue to maintain my utmost respect for human life and will not give up on treating my patients prematurely, I also promise that I will not futilely resist my patient’s death. Avoiding death should not be the goal of care, but rather ensuring the patient’s quality of life. I will focus on reducing their pain, maximizing their comfort, and addressing their fears, needs and concerns. I will also remind my colleagues that there is grace and kindness in stopping the heroic measures if continuing further treatments is not beneficial.

And finally, I now promise to make it a priority to walk with my terminally ill patients on their journey of discovering what matters most to them when their days on earth are numbered. I promise to be brave to initiate hard conversations to discuss what they wish for their final days and vow to do everything I can to honor that. I promise to lend a listening ear and to hold their hands when they are fearful and uncertain of what the future holds. I vow to walk with them and their family in the grieving process to provide any support that is necessary. I vow to advocate for the rights of my patients to remain free from pain and suffering, even if it means using a pain control regimen that is challenging to manage. And finally, I vow to find a balance between holding onto the hope of living longer versus the hope of dying peacefully. This balance will potentially help many terminally ill patients, like the patient mentioned above, to be able to die comfortably and peacefully with their family by their side..