To look upon medicine with a literary eye is something of a burden. If you have studied poetry, fiction and drama, no matter how much you have forgotten, you find yourself on the wards at times with literary phrases popping into your head that you cannot erase or make silent. Regarding sitting with a dying patient, “They also serve who only stand and wait,” from a poem by John Milton pops into mind. Recently, after a grueling day of caring for patients who almost to a person had fatal pathology, the phrase “in dubious battle” came to mind, and the often oxymoronic culture of “health” care as it “brands” itself in America vexed me.
In Dubious Battle is a novel by John Steinbeck. Steinbeck purloined the title from a phrase in Paradise Lost, the epic poem regarding the biblical fall of man by John Milton.
Paradise Lost is considered by many scholars to be the great epic poem of the modern English Language. The character of Satan plays a major role, of course, he being the character who will trick Adam and Eve into being ejected from the Garden. “In dubious battle” is a phrase used by Satan to describe the conflict that he and his band of fallen angels have lost in their conflict with God “in dubious battle on the plains of heaven.” The mythology is that Satan and co-conspirators in heaven, hating God and detesting his omnipotence, organize an armed uprising, lose and are thrown out of heaven by God.
In the poem, Milton employs oxymorons, a linkage of two ideas or words that are self-contradictory, such as “brilliant darkness.” The use of the adjective “dubious” by Satan is a nod to the oxymoron, because the entire notion of winning a fight with God is oxymoronic—you cannot win a fight against an omnipotent opponent.
Who cannot, having walked the wards for decades, find the notion, implicit in what we do, of “curing” certain patients, or “rehabilitating” certain patients, as oxymoronic compared to the actual data we must point and click and type into the electronic medical records to describe our patients’ conditions.
We cannot promise health to those whose journey has already taken them beyond its prospect. The obesity epidemic seems to be swelling like a wave, crashing upon those of us who work in the medical field. The changes of American culture, which I will call pathogenic, have brought us an opioid epidemic and an epidemic of obesity and they are causing our life expectancy to fall. They germinated during the youth of the baby boomers, coming to full fruition through their lifetimes. Now these massively obese souls have stumbled into the ranks of the aged and their multiple pathologies and physical impairments tethered to the expected impairments of aging itself kindle storms of acute disease.
I start a morning staring at the chart of a woman with a body mass index of 51. She presents with not one, but several potentially fatal events: her arm is infected; she has acute influenza and an acute exacerbation of her COPD with marked hypoxia. The patient’s age is seventy-something. She has had coronary stenting, lived for years with the metabolic syndrome of diabetes, hypertension and hyperlipidemia; she has had breast cancer bilaterally with infectious complications due to lymphedema, cellulitis and secondary bone infection of the spine, requiring months of intravenous antibiotics. She has suffered from diastolic heart failure and atrial fibrillation as well as chronic obstructive pulmonary disease; and she has chronic kidney disease.
This poor person is in dubious battle. We know she cannot win and we know that probably many medical adventures await her—those coronary arteries will get gummed up, the kidneys will fail completely and she will need dialysis. Chart review shows that she has been in and out of the hospital frequently over the past couple of years and the gravity of her morbidities appears on an upward curve.
Her aggressive consultants, her family informs me, are contemplating a biopsy of her vertebrae to make sure her bone infection is “under control.” I am fearful that procedure will not go well.
We are not caring for her health but attempting to react therapeutically to her multiple predictable disease states and the pathologies that are not random but rather the complications of a physiological illness for which we have little to offer. Severe obesity, mixed with aging, is a poisonous cocktail.
I have argued that one of our cardinal failures as physicians is to not honestly give a prognosis. There is a delicate dance in communicating with patients who have multiple smoldering and flaring morbidities and who have a very high likelihood of suffering severe complications and organ failures. On the one hand, it is not fair for us to maintain a pretense that patients such as the one whose clinical picture I sketched are going to be “cured.” On the other is the fact that professionally she deserves our empathy and in our communications, verbal and non-verbal, we must attempt to be of benefit. This is, of course, our duty to all patients but we must not forget it in our care of the severely obese or the addicted.
Taking a history from this patient was laborious and somewhat emotional. She was assisted by her daughter (whose level of involvement in her mother’s medical picture was revealed when she showed me her mother’s X-ray images on her cell phone.) I find it helpful, when trying to establish a relationship with a patient such as this one, to listen carefully to the story of her medical adventures and then acknowledge that she has had some really difficult encounters with disease over the past several years. “It sounds as though you have had a really tough time over the past years with these medical problems.” And then, of course, you have to listen to the response, which might give you a handle on what the patient and family have in terms of expectations. One can further connect by inviting the patient/family to explain the situation in the context of exactly how she and the family are coping with it—how and where she lives, who helps her, her functional abilities and disabilities. Being open to this information allows you to “go where the patient lives.” Doing so makes further conversations (about CPR or other intensive measures if they need be discussed) more contextualized within a relationship you have established.
In explaining what the medical care will be for this person’s acute problems a physician does not need to offer a general prognosis for anything but the acute problems. Should the medical situation deteriorate, giving as accurate a prognosis as possible may become necessary. In order to make that easier, establishing a relationship is a crucial step in patient communication.
By 2020 it is estimated that 75% of Americans will be overweight or obese.
To read more, see OECD(Organisation for Economic Co-Operation and Development) update from 2017: https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf