A Tipping Point

It was really a rather arrogant presumption so early in my career.

The secret sauce of medicine, I figured, was becoming an excellent diagnostician.  I devotedly memorized the signs and symptoms, the pathways and algorithms.  I strained to differentiate the pain in the chest due to suffocating myocardial cells from the stretching of the pleura or the lack of serotonin in the brain.  I cut my teeth on those early patient encounters.  Each experience was like a bookmark, a highlighted passage from a sacred tome.

I was blindsided by the realization that there was something else.  Something just as important.  And to my dismay, the art of prognostication proved to be just as complicated.  When I talk of the master prognostician, I'm not referencing one skilled at matching diagnoses to life expectancy charts.  This is the work of the accountant, the actuary.

I'm referring to the innate ability to understand when a person is dying.  Without such knowledge, our profession becomes the fodder of technicians.  Hands meant for healing can also do great harm.  How are such hands restrained?

There is a tipping point. Once past this imaginary line, aggressive intervention heightens pain and decreases quality and duration of life.  There is a reversal of physiology. Cure becomes the poisonous draught of good intentions.

We suffer a blindness to the important skill of prognostication.  We don't recognize or acknowledge the tipping point.  We hang on hope and deny reality.  It's easier that way.

Chemotherapy drip drips.

Scalpels snip snip.

Overzealous hands provide underwhelming outcomes.

It's an uncertain skill.  It can't be gleaned from text books or defined by lab values.  We learn through experience.  A strange mixture of clinical information, familiarity, and intuition makes some better than others.

But if you really want to help your patients, learn how to recognize death's distant footsteps.

Suffering at the end of life is not a requirement.