Treat the patient, not the numbers.

A lady with advanced secondary cancer in the liver was admitted with breathlessness and swelling in the lower limbs. After investigations, she was found to have a failing liver, abnormal kidney function and a large amount of fluid in one side of her chest. The fluid in the chest was drained and she felt better. Over the next few days, her doctor, Doc A, tried to ‘dry her up’ with diuretics (medicine to make you pass urine) and restricted her fluid intake. As Doc B had treated her for the advanced liver metastases before, the family requested that Doc B be involved in her care.

When Doc B first saw her, she was troubled by generalised aches and a strong desire to go home. She was told by Doc A that because of the fine, in-dwelling catheter in her chest she had to stay until it was removed. After explaining to her that Doc B’s immediate management aim was to make her more comfortable, Doc B prescribed an oral medicine and a tiny dose of morphine dripped over 24 hours. She had her first uninterrupted, comfortable sleep that night. The next day she felt comfortable and better. She asked Doc B if there was any possibility that she could be discharged home. Doc B informed her that it should not be a problem as long as all the ancillary home support for her had been arranged. “Even with the tube in the chest?” she asked. “Yes, even with the tube in the chest.” Doc B replied. The following day, blood tests showed that in addition to her deteriorating liver function, her kidney function had deteriorated dramatically. Doc A asked a kidney physician, Doc C, to advice on her kidney management. Doc C prescribed several medicines for her abnormal kidney results and asked her to drink as little as possible as she still had fluid in her legs. When Doc B saw her, she was feeling miserable and confused by the other doctors’ instructions. She had difficulty speaking and her throat was uncomfortable because she was feeling parched and she dared not drink at all. Doc B tried to clear her confusion and told her that she could drink for comfort. She was told by Doc B that she was unlikely to harm herself by drinking since the amount she could drink spontaneously would not be too much. Later that afternoon, the patient decided to be discharged as soon as all the home support services had been arranged. Doc B promised to visit if and when necessary. The patient went home with the fine tube in her chest. At home she had sips of her favourite drinks. She spent a few days at her home before slipping away peacefully in her own bedroom.

It is likely that some families have had similar experience as the scenario described above. Doc A was concerned and focused with treating the immediate problem her patient was experiencing. Doc C was interested in treating the numbers from the blood tests. However, Doc B was taking a holistic approach to the management of this poor lady with terminal cancer. Doc B was attuned to the patient as a whole. The deteriorating liver and kidney functions were inevitable in the course of her underlying condition. What were of most importance was how she felt and what she wished.

If you ever were in the same situation as the lady above, what would you want your doctor to do? Would you like him to treat the numbers or treat you as a whole?