Consultant, Not Counselor- by S. N. Busch
During
a recent case in which I was a circumstantial caregiver for an elderly patient
receiving home-based palliative care, the boundaries of medical authority
became starkly apparent. As New York's Medical Aid in Dying Act awaits Governor
Hochul’s signature, questions about how physicians define their role in
end-of-life care have never been more critical.
The
new physician was called in to evaluate the possibility of introducing IV
fluids. After a quick glance at the patient and the data we presented, he asked
to speak outside—and immediately adopted a psychological stance, urging
acceptance of decline and recounting cautionary tales of families who
"forced" care. He dismissed carefully documented observations,
referring to them as "an ICU you have going on in there," and implied
denial. We clarified that the previous doctor had requested the documentation and
asked for it each time he had visited. But the new one stated, "I will
determine… Don't try to be doctors. I am the doctor." The program's fixed
schedule (a physician every X days, a nurse every Y, a social worker every Z
weeks) was presented as immutable. Only after digging in our heels against the
rigidity of the schedule ("... So we let the patient dehydrate until the
next scheduled visit?") and the prescriptive worldview, did he offer a
superficial "We don't give up on anyone…" before leaving.
We
sought emergency care after the patient developed a fever within hours. He
improved dramatically within 48 hours of arrival in the ER, progressing from
unresponsive to communicating discomfort and needs.
Another
case involved a patient with endocarditis who was being pushed towards a choice
between biological and mechanical valve replacements. A cardiothoracic surgeon
was summoned by the internist. He answered all the patient's questions,
especially about the ramifications of each decision, neither of which sat well
with the patient. The on average once-a-decade repeated biological valve
replacement was not an attractive option, and being permanently on
anticoagulants frankly frightened him, given both his tendency to clumsiness
and having lost someone close to him to an overreaction to the same medication
he'd be put on. While he acknowledged that there were no shared genes, the
psychological barrier was present. The surgeon said to think about it. He later
returned, "I just examined your studies – I hadn't examined your case
myself earlier. I believe I can repair your valve." He explained what the
repair would involve, and also shared that we should understand that it was him
and us against the whole hospital. We gave him the go-ahead. Our joint decision
stunned other medical staff, who asked in passing, "So, what did you
choose?" when they saw the patient was post-op — and were shocked when he
said that it was repaired, not replaced.
The
contrast between these two clinical encounters illustrates how the integrity of
medical care depends on physicians maintaining professional boundaries,
offering clear, expert consultation without shifting into personal counseling,
so that patients retain genuine autonomy in complex care decisions.
That
cardiothoracic surgeon did a "world-class" job according to the
patient's cardiologist and internist. The surgeon was essentially acting as an
exceptional medical craftsman. He respected the psychological challenges, and
didn't try to counsel his patient out of them. He also went to bat for his
patient, resolving bureaucratic issues that had delayed the valve repair by
preventing an infected tooth from being treated.
One
physician expanded his medical problem-solving to the point of advocacy, while
respecting boundaries; the other contracted his medical assessment while
overstepping into counseling.
When
patients say, in whatever form, "Give it to me straight, Doc," the
request may reflect a desire for clarity, or for guidance. But it's often
interpreted as a cue to narrow the conversation, or to translate uncertainty
into preemptive finality. The line between clinical interpretation and personal
framing can shift, especially under cultural, societal, systemic, or political
pressures, given the ever-more multicultural makeup of both service provider
and service recipient. That shift is rarely acknowledged when it happens, and
ay, there's the rub.
Physicians
face many pressures: time constraints, systemic demands, institutional
expectations, and patient hopes, in addition to their own cultural and
religious backgrounds that can subtly influence how they present options or
outcomes. Patients sometimes expect or ask physicians to provide guidance on
existential or spiritual matters, but even then, physicians should clearly
direct them to chaplains, counselors, or social workers who specialize in that
support. The goal must remain clear communication grounded in medical
expertise, coupled with respectful acknowledgment of the patient's broader life
context, and appropriate referrals when needed.
And
policymakers should let physicians reclaim what brought them to medicine in the
first place: offering not closure, but care: Medical Aid in Living.
