Errors of compassion

I was rounding on our inpatient service one morning when I learned about a patient who had received adjuvant radiation therapy several years ago following resection of an early-stage lung cancer. Subsequent to this, she developed a metastatic sarcoma, therapy related, from which she was now dying. Our attending described this to our team on rounds as an “error of compassion.” Unfamiliar with this term, I asked for a definition. This situation, he explained, occurs when a physician recommends or prescribes a therapy, without solid evidence to support its use, because he or she feels an emotional need to do something to help the patient. The downstream side effects that result become errors of compassion. I realized that this situation was not isolated. I had heard a few years ago about a patient who had received an additional line of treatment for her refractory disease — likely to be of little benefit — and then went on to experience a serious adverse event from the chemotherapy.

Recently, Dr. Henry Aaron wrote a perspective piece in the New England Journal of Medicine entitled “Waste, we know you are out there” (N Engl J Med. 2008;359:1865), in which he describes the paradox of knowing that there is a lot of what we would probably call “waste” in clinical medicine, leading to unnecessary health care costs ... but this “waste” is hard to identify. Any plans for health care reform inevitably call for an elimination of this waste, but without knowing exactly what it is, it is hard to come up with plans to cut it out.

Most would agree that the two situations I described above are probably examples of waste. In the end, the patient didn’t benefit — in fact, the patient was harmed — at the significant expense of an unnecessary treatment.

I think that the challenge to addressing this kind of waste in medical oncology arises from one of the operative words in the term “errors of compassion,” which is not “errors” but “compassion.” As doctors, we are continuously trying to do the right thing for our patients. And in a field — oncology — that is in constant emotional overdrive, with life and death stakes and a daunting opponent, “Cancer,” the pressure to do more, even in the absence of convincing data, is ever present. Taking on this issue invokes the implication that good, honorable, respectable people who are just trying to do the right thing may in fact be unintentionally doing the opposite. And how can you convince someone of this while stripping away the emotional overtones? I think that an important part of this involves addressing conflicts of interest, and making sure that aggressive, risky care is being performed for the primary benefit of the patient first and foremost. And beyond this, perhaps a frequent review of local standards so that even when doctors are just trying to help their patients, reasonable practices will prevail.