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Last summer, Dr Arnold Relman, the former editor of the New England Journal of Medicine, fell down some stairs. He banged his head on the slate floor of his Boston home, fractured several vertebrae and was admitted to hospital for a series of interventions including intubation and intensive care. He describes his experiences in a recent piece for The New York Review of Books (“On Breaking One’s Neck”), which treats the disaster with medical dispassion. His commentary has the serenity of a senior professor contemplating some intriguing scientific phenomenon: “The medical team immediately started cardiopulmonary resuscitation efforts as oxygen was being pumped into my lungs through the tracheostomy … Within two minutes my heartbeat resumed.” It’s easy to forget that it’s his own near-death experience he’s talking about.
In an interview about the accident, Relman, who is 90, made an unusual observation. “They were too solicitous. They wanted to give me too much medication. They were too concerned that I should not have any symptoms – no pain, no anxiety, no sleeplessness.” This is not the complaint we usually hear, though it can be true. Some doctors do aim to abolish all discomfort; many patients expect it. Like the legendary householder who dials 999 when he can’t find his glasses, there will always be some patients who expect you to abolish every scrap of irritation from their lives, from a hiccup or a tickle to a bad temper.
Relman’s concern is that there is a fine balance between resolving symptoms and generating more with treatment. Sedation and sleep medication can cause serious problems, especially in the elderly, who are vulnerable to falls, fractures and pneumonia (too drowsy to navigate safely, too slumped and sleepy to cough properly and keep their lungs clear). Most analgesia has side effects, from constipation to gastric bleeding to overdose.
It is not unusual for patients to refuse symptom relief, especially the elderly, who are generally regarded as being tougher than everyone else. (Clinical staff share a non-evidence-based but widely disseminated scale of “hardness”: at the top are the old ladies who break both hips but don’t think to mention it; at the bottom are the strapping young men who fall into a faint at the word “injection”.) Relman is far from being the only nonagenarian who would rather sit in suffering, watching the clock all night than risk the befuddlement that can come with strong painkillers.
But it can also be bad medicine not to treat. Symptoms themselves cause side effects. Pain prevents people from moving freely or inhaling deeply and so contributes to other risks – chest infections, blood clots, musculoskeletal problems. Pain is bad for mood, too, and low mood is bad for rehabilitation and healing. Even minor symptoms, such as itching or constipation, can become unbearable.
Despite all the evidence and guidelines, sometimes nothing is quite right. Everything has risks. What can be helpful (and this is where complementary medicine often succeeds and conventional medicine sometimes fails) is acknowledging that problems exist – and matter – even when they’re unpleasant, even if they’re unfixable. “Just sit with it,” as my Buddhist friend used to say, a phrase that struck me as annoyingly prissy. But perhaps he was right. There is medicine in all kinds of things other than medication: in helping people to understand what’s gone wrong, in taking away fear, in kindness. There is no medicine without this.
Sophie Harrison is a hospital doctor in South Yorkshire. This column appears fortnightly.
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