Giving Patients the Hope to Heal

It is good practice to never give unrealistic hope to patients with chronic or terminal conditions. It is logical that the extraordinary disappointment and pain associated with watching a loved one deteriorate from a terminal condition is intense enough without the added torment from crushed hopes for a cure. Furthermore physicians must practice in the scope of evidence-based medicine that reasonably predicts prognosis via staging and severity indices in the context of a particular patient. 

But too often I hear my patients tell me that other doctors give them an excessively morbid prognosis in the setting of non-terminal conditions, often using scare tactics to persuade the patient to accept invasive therapy. The classic case is lumbar disc and vertebral fusion surgery for non-traumatic discopathy without cord compression. Although the evidence for surgery is very weak, every day patients have such procedures. When they come to me for consultation for comprehensive non-invasive medical care, they reveal that their doctor/surgeon told them it was the only way to help treat pain and avoid eventual paraplegia. These seem to be scare tactics to perform unnecessary procedures. It may even qualify as malpractice.

The way I approach it, all diagnoses need to be divided into reversible and irreversible conditions. Although it is not always clear in which category a certain condition fits, it is up to each practitioner to make a judgment based on his or her clinical evaluation and the evidence to date.

Reversible conditions should not be automatically associated with morbid prognoses. But what to say about irreversible conditions? COPD, chronic kidney disease, systolic or diastolic heart failure, HIV, chronic liver disease, and chronic atherosclerotic disease all are irreversible illnesses that have staging scores that can be used to assess severity. But except in the cases of morbidly severe forms of disease, it is almost impossible to predict quality and length of life without individualizing such analyses to the particular patient involved.

I can fairly assess prognosis after getting a sense, over six months or so, of a patient's capacity to make the comprehensive lifestyle, dietary, physical, and attitudinal changes necessary in any real therapeutic program. If even after ample support, education, hand-holding, follow-up, and adherence to medication regimen, a patient cannot change his/her lifestyle, then I think it is fair to proclaim an overall poor prognosis. But if a patient with severe disease at baseline is able to eat the right food, take appropriate medication, uplift their emotional and psychological well-being, and get into excellent physical shape, then I would be very hesitant to say that they cannot heal to a significant extent. That is not to say there aren't significant structural problems in whatever organs involved in their disease, but still, the potential to heal is clearly evident in such cases.

What does "healing" mean in the context of irreversible disease? Pathophysiologically, it may refer to the slowing down of the rate of disease progression, and possible reversal of disease processes. Clinically it refers to improved functionality and quality of life. These all can occur as a result of a comprehensive therapeutic program, which can be implemented for any chronically ill patient.

My colleagues may scoff and say, "But how many patients realistically can transform to that extent?" My answer is that many do. Catalyzing such transformation is what I consider my primary task. While it is easy to provide medication for illnesses, without the transformation, healing is unlikely.

I believe the word "heal" is quite useful, especially in conversation with patients. This word connotes more than mere treatment, but addresses something internal and essential within the patient. Other than in the setting of some infectious diseases and some treatable cancers, I seldom use the word "cure," since chronic illness is exactly that - chronic. But it doesn't have to be progressive. If clinicians can slow progression, they can improve lives, and can avoid giving morbid prognoses unnecessarily.

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