When 90-year-old American widow Norma Bauerschmidt was diagnosed with terminal cancer, it was far from being the beginning of the end. Rather than undergoing palliative chemotherapy, she chose a rather more novel way to spend her last few months: a road trip across America, travelling more than 13,000 miles and visiting 34 states. Among other activities, she enjoyed a basketball game in Atlanta, harvesting hazelnuts in Washington, St Patrick’s Day in South Carolina, visiting Yellowstone National Park and touring along the Massachusetts coast.
This caught the imagination of the world’s press and the thousands of people who followed her journey online. As a cardiologist who is passionate about end-of-life care, I was one of those cheering her on.
The principle ‘First, do no harm’ (‘Primum non nocere’) is a founding tenet of medicine. It is thought to originate from the Hippocratic oath of the 5th century BC but I believe it is just as important today. One of my first thoughts on seeing an acutely unwell patient is: are they ill because of something we have done — say, because of an adverse drug effect? The next question is whether my intervention will make them worse through aggressive treatment before a diagnosis is clear.
The risk of unnecessary treatment is particularly high when it comes to patients at the end of their lives. Sometimes, like in the case of Norma Bauerschmidt, it may be better for doctors to do nothing.
To ‘do no harm’ doctors must learn to see the patient rather than the disease. Despite training to be a heart specialist, I am often less interested in the results of scans and blood tests than in how the patient looks, feels and sounds.
From my clinical practice, the best example I saw was when a husband and wife came to see me in clinic. She was nearing retirement but, during a private health check, a scan had revealed a significant problem with her heart: one of the heart valves was critically narrow and undoubtedly would require surgical intervention in the near future.
But this wasn’t what I was interested in. I was interested in the fact that the wife held her husband’s hand as she shuffled into the clinic room, that her husband answered all the questions and that her behaviour was odd and she made little sense.
There was no mention of this in the referral letter and I was perplexed. I asked her husband and he said a few months ago she’d been diagnosed with early onset dementia and he was now having to care for almost every need.
When I assessed her formally her mental score was 0/30, suggesting her condition was severe and rapidly progressive and the outlook grim. I said that the heart valve was inconsequential relative to her rapid mental deterioration and that I felt it would be inappropriate and unkind to continue to monitor her or even consider treatment.
Despite this bad news, her husband was relieved. He was concerned, having come to the outpatients’ department, that his wife would have been subjected to a battery of ongoing tests and treatments which he felt would be inappropriate. His plan was to move with his wife to be closer to their children near the coast and enjoy their limited time left together, free from medical interference. I said this was simply the best advice I could give and if it was for a loved one of mine I would want the same.
Subjecting the patient (and her husband) to further tests in order to monitor a condition that ultimately would not need intervention seemed to me pointless and cruel.
In my view, the founding tenet ‘first, do no harm’ should be placed at the forefront of every interaction between doctors and their patients. As the population becomes older, more frail and accrues more diseases, the principle will become ever more important.
The details of the case were changed to preserve patient confidentiality.