Special Report ‘. and Do No Harm.’ Steven Hetts, Alison Werne, and Grant B. Hieshima During my 20-year evolution with this new complex neurovascular disease. Although en- specialty, I have been unable to emotionally dovascular approaches have often resulted in detach from my patients, and recently I have profound advances, there is very little mention begun to explore, with the help of my coau- of the occasional devastating failures. thors, the adaptive mechanisms that permit In medical school, doctors are introduced to continued survival.—G.B.H. general guidelines to assist patients and fami- lies through catastrophic illness and death. Un- Doctors are trained to heal, not to harm. fortunately, there has been a paucity of training When, in the course of medical practice, the for constructive transition through grief experi- condition of a patient worsens instead of im- enced by the physician when a devastating out- proves after a doctor has intervened, strong come occurs in a patient (5, 6). A common emotions, including sorrow, remorse, and an- belief is that the physician, in maintaining an ger, can be evoked on both sides of the doctor– objective and scientific approach to patient patient relationship. However, in pursuit of heal- care, is insulated from the emotions attached to ing patients, doctors often forget the wisdom of the suffering of the patient and family (7, 8). the oft-maligned aphorism, “physician, heal thyself.” After a medical tragedy occurs, most The ability to intellectualize the process of dis- doctors turn their introspection not on their ease and the complications associated with emotions, but on their knowledge. Instead of treatment are often viewed as desirable and can coping with the grief that naturally arises over lead to further scientific advancement. It is also the injury or loss of a patient during a proce- thought that the young practitioner who is less dure, many physicians intellectualize the tragic experienced and unable to detach from the experience and focus their attention solely on emotional impact of tragedy may, over time, the details of the medical procedure (1–3). become better able to cope with failure and thus They, like myself (G.B.H.), search for a tangible avoid feelings of grief, guilt, and shame result- procedural mistake that can be corrected to ing from involvement in a catastrophic out- ensure that the same tragedy will not occur come. again. Showing emotion runs counter to the To begin with, not all poor outcomes from conventional wisdom that doctors should be- complex surgery are emotionally tragic. If, for have like objective medical scientists in clinical example, a patient were brought into a hospital settings, but unless doctors learn to cope with suffering from an immediately life-threatening their own grief in a natural way, they may emo- condition such as an intracranial hemorrhage, a tionally injure themselves and their families (4). surgeon’s failed attempt to save the patient’s In surgical fields in which the stakes are high- life would be unfortunate and sad, but not tragic. est, so too are the risks of the occurrence of Surviving emotionally is less difficult when a clinical tragedies. Interventional neuroradiology patient’s death results from what Charles Bosk, has had its share of triumphs and failures during in Forgive and Remember: Managing Medical its short history. Spawned by neurosurgery and Failure, terms “expected failure” (1). “Patients adopted by radiology, interventional neuroradi- who are hopelessly ill with terminal diseases fall ology has led to the development of new mate- into this category. What happens to these pa- rials, methods, and training for the treatment of tients . could not have been otherwise” (1). From the University of California, San Francisco Medical Center. Address reprint requests to Grant B. Hieshima, MD, Neurovascular Medical Group, Inc, Department of Radiology, UCSF Medical Center, 505 Parnassus Ave, Room L352, San Francisco, CA 94143-0628. Index terms: Patient-physician communications; Interventional neuroradiology, complications of; Iatrogenic disease or disorder; Special reports AJNR 16:1–5, Jan 1995 0195-6108/95/1601–0001 q American Society of Neuroradiology 1 2 HETTS AJNR: 16, January 1995 The patient’s family are generally prepared to form a final angiogram, because we could no longer cope with the loss of their loved one, who may treat the lesion, and a set of films would be performed have been languishing in pain for years with for the gamma knife treatment. We decided to pro- symptoms of a terminal illness. In these circum- ceed and performed one more injection with the pa- tient still anticoagulated and our complex catheters stances, a physician will attempt to treat a pa- still in place in the feeding arteries to the arteriovenous tient despite the likelihood of a poor outcome. malformation. Within moments after the injection, she Statements such as “no one else could have cried out with pain, and as I tried to comfort her, she done it better” and “the patient would have been asked for her husband and told me she was dying. We worse off without treatment” can salve the phy- treated her vigorously with medical therapy, and the sician’s conscience through rationalization. The neurosurgeon examined her repeatedly as she pro- physician failed in an attempt to save a patient’s gressed to coma and pupillary dilatation. She was life but did not lose a life that could have con- pronounced brain dead a short time later. Then I tinued much longer without treatment. helped her husband prepare the papers for organ do- Unlike emergency medicine or oncology, in- nation and subsequent funeral arrangements. During terventional neuroradiology usually treats cases this time I tried to comfort him, and he tried to comfort his young son who also was grief stricken. I eventually in which diseases, although dangerous in the helped prepare her body for transport so he could take long term, are not immediately life threatening. her home. During this interaction I tried to function as Patients often arrive at a neuroradiologist’s of- a “professional” and help the family in the transition fice on their own two feet, with few outward through shock and grief, but I did not know what to symptoms of disease, and sometimes leave the do with my own emotions. hospital permanently injured or dead. These are I felt a lancelike pain that would drive to the very the outcomes that are truly tragic, both for the center of my soul and carry with it feelings of guilt, patient’s family, which is emotionally unpre- shame, inadequacy, anguish, and sorrow. I retreated pared to cope with the loss of an asymptomatic to my office and felt a great sadness, and as my eyes filled with tears I said: “I am not supposed to kill my loved one, and for the physician, who may feel patients.” I can remember the events as if they oc- that his actions instead of the disease killed the curred yesterday. I reviewed her films and the se- patient. Instead of saving lives already lost to quence of events again and again until I located what disease, doctors may feel they have lost—by I believed to be the source of hemorrhage and why the their own hands—the lives entrusted to them. procedure caused it. I would try not to miss something The strong emotions that can well up within a like this again!—G.B.H. physician during medical tragedy are perhaps best expressed by personal example, based on Unfortunately, there are other possible an actual case: causes for catastrophe, and we cannot control everything or foresee all possible complica- It was 10 years ago when I met with the patient and tions. The systematic identification and preven- her husband. They were both in their 30s, and she had tion of further similar events is one method of recently recovered from a large hemorrhage caused compensation and self-forgiveness, but it is by a 2-cm arteriovenous malformation in the right probably only a partial solution. Intellectualiza- basal ganglia. I described the natural history of arte- riovenous malformations and the therapeutic options, tion and searching for procedural mistakes in- including surgery, embolization, and stereotactic ra- stead of accepting and working through the diosurgery. Our gamma knife unit at that time had an grief that is concomitant with human tragedy effective target area of 1 cm. I proposed a treatment can, in the long run, only add to the physician’s option of embolization to reduce the size of the arte- woes. Losing a patient is analogous to the death riovenous malformation followed by gamma knife of a relative, friend, or other loved one, in that therapy for the residual portion. We also discussed the the doctor–patient relationship rests on a strong uncertainty of the outcome and the risks of each pro- foundation of trust. Thus, failure to sort out the cedure. The patient and her husband were very opti- emotions elicited during a medical tragedy may mistic and wanted to proceed as quickly as possible. prove detrimental to a physician’s own emo- The treatment went very well, with what we esti- mated to be a substantial reduction in the portion of tional health. the arteriovenous malformation supplied by the len- The mourning process is a human adaptive ticulostriate arteries. There was a residual arterio- advantage that allows “maximum survival char- venous malformation supplied by perforating acteristics.” In his article “A Model of Mourn- branches through the insular cortex that we could not ing,” Mardi Horowitz, the noted psychiatrist, treat. There was some discussion of whether to per- separates the normal psychodynamic grieving AJNR: 16, January 1995 NO HARM 3 process into several cognitive and emotional catharsis—doctors put themselves through un- phases (9).