Chapter 20. How to deal with failure of treatment?

Dr. Yeshwanth K. Amdekar, DCH, MD (Pediatrics), FIAP

Many medicines few cures

                                                            –Benjamin Franklin

Success is not final, failure is not fatal, it is the courage to continue that counts

                                                            -Michael Fox

Meaning of “getting well”

To a patient, it connotes total recovery back to original state of health. To a doctor, it refers to recovery to an extent possible depending upon multiple variables such as type of the disease (curable, controllable or incurable), stage of the disease (early or late diagnosed) and response to standard treatment (response also depends on individual patient’s health and immunity). In other words, “getting well” is as per the expectation – patient expects total recovery and doctor expects what is best possible in a given

Doctor must anticipate progress

Once final diagnosis is achieved and standard protocol of treatment is defined, doctor must make time-wise anticipation of expected progress, considering variables related to disease and health status of the patient. Time to time assessment during treatment period would ensure that patient is progressing as per anticipation. In case of any deviation from expected course of events, doctor is timely warned about likely change in management that would again ensure necessary correction. Such an anticipation is important as much as the correct diagnosis and treatment. For example, patient diagnosed to have acute bacterial pneumonia is expected to show improvement in tachypnea first, within 2-3 days, followed by reduction of fever over next few days and cough may worsen for a while at that stage before it resolves completely over next few days. Such an anticipation would not worry a doctor and in turn a patient, even if cough worsens as it was anticipated as a course of right direction of recovery. However, if temperature is normal but tachypnea persists, your antenna should go up to trace the cause, it may denote septic shock. Similarly, first symptom to improve in correctly treated typhoid fever is feeling of well-being and return of appetite and doctor finds feel of abdomen improving but fever continues to be high at that stage. So, for a patient who has sought treatment for fever feels he is no better but doctor knows that recovery is on the right path. Such is the importance of anticipation of course of events during treatment.

Need to counsel and document anticipated progress

It is not enough to know the diagnosis, treatment and prognosis or anticipated progress but equally important is to counsel the patient and document the same for records. Every doctor must develop skill of counselling and make a habit of documentation. It signifies honesty, transparency, accountability and responsibility. It instils faith and mutual trust that has a positive impact on outcome. As discussed above, patient must be informed about the best possible outcome which may change over period of treatment because of many variables. At times, patient may not be happy with the progress that may be short of his or her desired expectations, even when you are satisfied.  In such a case, patient has a choice to take another opinion and one should suggest it upfront.

But when patient does not get well as expected –

Problem arises when patient’s progress does not keep up with what is expected and anticipated by a doctor. That is how time to time assessment of the course of events are important and should be informed to the patient or their relatives. Earliest deviation is spotted, not only patient is informed about change in the course of events but also there may be a change in outcome different than what was expected to begin with. It also needs to be freshly counselled and documented. Doctor must inform why in his view, course got deviated and how he is likely to correct the same. When things are not going the way they should, best way is to talk to the patient more often and try to answer patiently and calmly all doubts raised or at times even allegations made against the doctor. It is said that anger is demonstration of pseudo-strength of a weak person. One must not get defensive but inform the truth. It is important to let patient know that you have put in best of the efforts but they may not always equate to best of the outcome. Equally important is to let the patient see your best efforts and concern about the situation. Honesty pays and so if there are any mistakes inevitably occurred, it is best to own them instead of defending them. Always offer upfront a chance of getting second opinion and let the patient select his choice of second opinion. Most times, patients would ask a doctor whose second opinion they could seek and in such a case, suggest 2-3 alternatives so that they can still choose one of them. It proves your transparency. Once patient has developed faith and knows doctor is doing his best, invariably he would leave choice of second opinion to a doctor. It means half the battle is won. After all patients are not bothered about how much you know but they want to know how much you care. So not only care always but it also must be evident to a patient.Modesty and honesty are two virtues that come handy in difficult situations.

Personal notes

During training days, responsibility is shared by seniors but in private practice, one is totally responsible for the outcome. Parents are not satisfied unless child completely recovers and at times, one has to face unrealistic expectations from parents. I recall a child suffering from typhoid fever who was improving well with regaining of appetite and energy but was not yet afebrile. Fever is the last symptom to disappear in typhoid. In spite of explaining these facts and assuring that fever would soon disappear, parents were upset. It took some time for me to learn by myself how not to argue with parents but suggest alternative opinion. I also learnt to anticipate “troublesome” parents and sought help in time from senior colleagues. It is ideal to convey a possibility of a rare exception of treatment failure due to patient’s inability to respond to medicines. In such a situation, I assess the attitude of parents and suggest a second opinion.

Take home message

Medicine is a science of uncertainty and doctor’s act by probability supported by knowledge, experience and even an intuition. Naturally, it is important to convey to a patient that best efforts are guaranteed but not equating to best outcome. However, it does not mean that you paint a gloomy picture each time to be defensive, it may fire back. But what is important is to anticipate, inform, counsel and document. Be honest and don’t hide mistakes, to err is human. Be answerable to yourself and not blame others.

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