Judy Citko gave me a heads up about an article in the pediatric literature titled, "The Darkening Veil of 'Do Everything.'" (PediPal, where are you? An opportunity waiting to happen! www.PediPal.org is available...)
I'm sure each of us has heard the phrase, "Do everything." As in a clinician saying, "Do you want us to do everything?" Or a surrogate decision maker saying "I want you to do everything for him!"
In the Archives of Pediatric and Adolescent Medicine, Chris Feudtner and Wynne Morrison from Children's Hospital in Philadelphia authored a nice thought piece about the dangers of "do everything." Among the arguments:
- We can't do everything. "One simply cannot simultaneously cradle a grievously ill infant in one's arms and at the same time insert vascular cannulas for extracorporeal membrane oxygenation; nor can one hold a loved one's hand while they are dying at the same moment that the code team yells "clear" and attempts to defibrillate the patient's heart."
- The term is not specific. What the heck does "do everything" mean, exactly? Does it include high quality high intensity palliative care? Families don't know the whole range of medical options.
- This term cuts off meaningful discussion between clinicians and family. "We already know what they want."
- This term is a cry of distress. W should attempt to puzzle out the specifics of what type of care are most appropriate to the patient's goals and circumstances. But when we do so, responding to emotion is often forgotten, considered outside of our role, or not prioritized. Make sure to respond to the affect behind the statement as much as the content.
- As the pace of the technological imperative accelerates - extending life by seconds or minutes with medicines, devices, and machines - the "veil of 'do everything' grows darker."
The authors conclude by arguing that the phrase "do everything" is dangerous nonsense, and call for a moratorium on using the phrase. I prefer a "ban" to a "moratorium," as a moratorium is temporary, and I don't see any reason for a second life for this particular phrase.
This is an actionable item. Let's all, in each of our healthcare settings, use reasoned arguments to promote a ban on the use of the phrase "do everything."
How would we accomplish this ban?
- Education. Many of us teach trainees - students, residents, nurses, fellows, or faculty. Make it a point to encourage your trainees to stop using the phrase, and ask them to stop others from using it.
- Speak up when you hear the phrase. Even in the heat of the clinical encounter, you can gently say something like, "I know Dr. Smith just used the term "do everything," but I worry that that term may not be specific enough. Let's talk about how we might help your mother." The article provides some terrific suggestions for language. Give feedback to trainees who you hear use the phrase, and encourage them to spread the ban.
- Make the message go viral! Spread the word via twitter, facebook, and your favorite social media sites. Mine is currently Strava (OK, maybe not Strava).
by: Alex Smith