Medicine can always offer one more intervention, but does more treatment always means better care.
By Kathleen D. Benton, DrPH, MA
President & Chief Executive Officer
Modern medicine can do extraordinary things. We can diagnose disease earlier, treat conditions that once had few options, sustain life through sophisticated technology, and give people time they might never have had a generation ago. Those advances are worth celebrating. But they have also created one of healthcare’s most difficult questions: Just because we can provide another treatment, does that always mean we should?
It is a question I have confronted throughout my career in medical ethics, palliative care, and hospice. And I believe our difficulty answering it has contributed to what I think of as the medicalization of death. When someone is approaching the end of life, healthcare can remain intensely focused on the disease. What treatment comes next? Is there another medication to try? Another procedure? Another hospitalization? Another technology that might extend life?
Those can all be appropriate questions. But they shouldn’t be the only questions we ask. We also need to understand who this person is, what matters most to them, what they are hoping for, what they are afraid of, and how they want to spend the time they have. We need to ask whether the treatment we are considering is likely to help them achieve those goals—or simply expose them to additional burdens.
In my conversations with patients and families over the years, I have seen what can happen when those questions come too late. Families may understandably be waiting for the next test result or hoping there might be one more treatment available. Then suddenly the situation changes and the call to hospice becomes urgent. Instead of having weeks or months to benefit from hospice care, a patient may arrive during the final days—or even hours—of life.
That isn’t a failure of the family. It reflects a healthcare system that has become extraordinarily skilled at continuing treatment but isn’t always equally skilled at helping people understand when the goals of care may need to change. Hope is powerful, and families should never be made to feel that choosing comfort, quality of life, or hospice means they have somehow stopped caring or given up.
There is still something medicine can do
One reason these conversations are so difficult is that stopping a treatment can feel like stopping care. But there is an enormous difference between saying “There is nothing more we can do” and asking “What can we do now that will matter most to this person?”
There is almost always something more we can do. We can manage pain and other symptoms, reduce fear and anxiety, help someone remain at home when possible, support family caregivers, create opportunities for meaningful conversations, and help people understand what is happening and prepare for what may come next. Perhaps most importantly, we can make sure the person doesn’t disappear beneath the medicine. Their diagnosis is part of their story, but it is not their entire story.
This is one of the reasons I believe healing can continue even when curing is no longer possible. Healing may look different at that point. It may be physical comfort. It may be repairing a relationship, resolving a fear, having an important conversation, or simply having meaningful time with the people someone loves. Healthcare still has an important role to play in making those things possible.
We need the courage to ask a different question
There is also an ethical dimension to this issue. There are times when an intervention may be medically available but unlikely to provide meaningful benefit—or when its burdens may outweigh what it can realistically accomplish. Yet our healthcare system often makes it easier to continue down the treatment pathway than to stop and reconsider where that pathway is taking someone.
I believe we need to become much better at making that distinction. This isn’t about denying people care, nor is it about deciding that someone’s life has less value because they are older, seriously ill, or living with disability. It is about recognizing that more medicine and better care are not always the same thing.
Patients deserve honest information about what a treatment can realistically accomplish, and families deserve the opportunity to understand the tradeoffs. Clinicians also need the training, time, and support to have these conversations before a crisis forces everyone to make extraordinarily difficult decisions under enormous pressure. Palliative care and hospice can be important parts of that answer, but the larger change needs to begin much earlier in someone’s healthcare journey.
We need to become as comfortable asking “What matters to you?” as we are asking “What treatment comes next?” Those two questions don’t have to be in conflict. Sometimes understanding what matters most to a person will lead to another treatment. Sometimes it will lead to a different kind of care.
At the end of life, our responsibility is not simply to keep doing everything medicine allows us to do. It is to understand the person in front of us—their story, their loves, their wishes, their fears, and their hopes—and make sure the care we provide honors the life they are living.
Knowing when treatment is helping us accomplish that, and when it is not, may be one of the most important responsibilities we have in healthcare.
