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July 7, 2021

What doctors can learn from 'one-in-a-million' outcomes

Daily Briefing
    Editor's note: This popular story from the Daily Briefing's archives was republished on Jun. 17, 2022.

    Writing for the New York Times, Daniela Lamas, a pulmonary and critical care physician at Brigham and Women's Hospital, discusses "the one-in-a-million outcomes, the patients who surprise and humble us" and how providers can learn to deal with these unique cases.

    Toolkit: The physician executive's guide to patient-centered communication

    The patient who changed her

    Lamas writes that as a critical care doctor, she becomes "nervous at the very idea of miracles"—not the religious or supernatural kind, but those extraordinarily rare outcomes that "beat the odds." She explains that while miracles are often what her patients' families desire most, they are not something that she can give them.

    Then Lamas had an experience with a patient who caused her to reconsider her feelings about these exceedingly rare recoveries.

    Her patient was a young father with Covid-19, suffering from pneumonia, sepsis, and "devastating" bleeding, kept alive only by a ventilator and a lung bypass machine. Over the next few weeks, she writes, it became clear "that the damage to his lungs was not survivable." Lamas' team recommended to the patient's family that they stop all aggressive interventions, but the family asked them to wait a few days before taking him off the machines.

    That same night, Lamas writes, she and her team "watched in amazement as [the patient's] oxygen levels start to rise, slowly at first and then steadily." A year later, Lamas' patient—although still in recovery—is at home with his family, who send her photographs that she "marvel[s] over."

    'A great save can be complicated'

    Lamas writes that although her patient's story is "remarkable," she is somewhat reluctant to share it because she doesn't want to mislead patients who, like most people, "when faced with illness, secretly believe that they may be the outlier." She adds that while this desire "to beat the odds is what pushes doctors to be great," it can, "if taken too far … lead to false hope and suffering for our patients and their families, protracted critical-care admissions and futile procedures."

    As Lamas explains, giving "too much weight" to "that one patient who made it home despite our predictions" can unduly influence "our decisions and recommendations." While providers "do not want to deprive our patients of the chance to surprise us," she writes, they must also ask themselves "how many deaths [they] are willing to prolong" for the chance of one miraculous recovery.

    "A great save can be complicated," Lamas writes. There is a "vast world between survival and true recovery." And even when patients do end up surprising their doctors and make it out of intensive care, they might still never recover enough to live the way they had before. A patient may also be "saved" only to spend months in long-term care hospitals or dependent on ventilators.

    Pushing forward with patients

    However, despite these concerns, Lamas writes that "for better or worse," she is more willing to push forward with her patients than she once was, giving "that extra round of antibiotics or that one last trial of high-dose steroids."

    And although Lamas does not try to continue additional treatments for too long and risk causing pain, she does allow herself to "hope for a few more hours or a few more days" as she prepares her patients' families and herself for the likely possibility that her patients will not survive.

    For instance, Lamas recently had a cancer patient whose liver and lungs were failing. Despite the grim outlook, the patient's family was waiting until Monday to take her off the ventilator "to give [the patient] time for a miracle." Unfortunately, however, the patient's family realized by Saturday night that "there would be no Hail Mary save, no reason to wait until Monday."

    However, Lamas writes that while, in this case, "[t]here would be no miracle … perhaps there would be peace. It was time to say goodbye." (Lamas, New York Times, 7/2)

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