“Missing the Forest for the Trees”


Today I saw a patient whose management in a local ER exemplifies having “missed the forest for the trees”. A 66 year old man with an end-stage brain tumour presents with lower abdominal pain 3 days ago. The patient has a PPS=30% and has a foley catheter in situ. The ER MD carries out a classical lab workup that discovered a low serum potassium, high BUN, high creatinine, and bacteruria. The ER MD administers IV fluids, potassium supplemenation, IV antibiotics, and a Rx for opioid analgesics. On my examination today, the patient is in 10/10 pain and his urinary bladder is distended to the level of his umbilicus. My diagnosis is a blocked catheter. A catheter change immediately provides complete pain relief.

The problem with this case is multifold:

1. There was no attention to the principles of “patient-centered care”. The MD’s lab workup was not consistent with the patient’s documented preferences for a completely conservative palliative mode of care (aka “comfort measures only”). Moreover, the MD was so absorbed with futile minutia that a blocked foley catheter was not diagnosed.

2. The MD focused all his attention on details (the micro) that were completely irrelevant (futile) given the context (the macro) of this case and the expressed goals of care by the patient.

3. From the stand-point of “Evidence-Based Medicine”, where is the evidence that micromanaging issues like potassium levels, hydration status, and the use of antibiotics for asymptomatic bacteruria improve survival and/or QOL in end-stage patients?

Thus, I wish to advise all healthcare professionals to advocate for patient-centered care, consider the clinical context while looking at the macro, not just the micro. In so doing we will not proverbially “miss the forest for the trees”.

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About drvincentmaida

Consultant in Palliative Medicine & Wound Management, Assistant Professor, University of Toronto & McMaster University, Researcher & Author.
This entry was posted in Bioethics, Distributive Justice, Palliative Medicine, Promoting PCC & PE. Bookmark the permalink.

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