First Do Not Abandon
Physician abandonment of the imminently dying patient is an ancient medical tradition that is deeply rooted in the culture of biomedicine and has stood the test of time. The origin of this curious practice can be traced back to Hippocrates1,2 who supposedly recommended that physicians should abandon the desperately ill. Hippocrates is thought to have made this recommendation for the following reasons1:
(1) physicians should avoid futile therapy in the face of terminal illness and
(2) physicians who stay with the dying patient until the end could be subsequently blamed for the death and also acquire a reputation for high mortality rates.
Indeed, doctoring was a risky business in olden times, especially if your patient was a powerful person and also happened to die when in your care.
When Hephaestion, a Macedonian nobleman, closest friend and alleged lover of Alexander the Great was terminally ill with a fever, his physician Glaucias placed him on a strict dietary regimen. But when the noncompliant Hephaestion died after "eating a fowl and drinking a gallon of wine," Alexander the Great blamed the physician for his friend’s death and promptly executed the unfortunate Glaucias. Such incidents must have greatly influenced ancient physicians who defensively responded by safely distancing themselves from the terminally ill.
In Byzantine3 times too, physicians continued to abandon their patients when it became apparent that they were dying. When the Byzantine emperor Justinian I became ill during the Justinian plague pandemic (541-542 AD) and looked like he was imminently dying, historian Procopius noted that the emperor’s physicians abandoned him "because he was considered to be already among the dead". Similarly when Alexius I Comnenus (12th century) was seriously ill, his physicians made what probably constituted heroic efforts in those times (medications, phlebotomy, and even surgical stomach cauterization) to save him. But when such attempts failed and it became apparent that Alexius was dying, his physicians apparently rubbed some myrrh (maybe to mask unpleasant odors) on his head and left. The emperor’s daughter Anna Comnena, a well-known historian and medic, documented that the royal physicians, "left for their homes, not because they had an urgent reason but because they knew that fatal danger was approaching the Emperor."3
Patient abandonment may be either overt (physicians withdraw completely from the care of the dying patient) or more subtle (physicians participate in care provision but indicate discomfort through unconscious non-verbal communication or by distancing themselves).
Fear of abandonment4,5 is a primal and common fear that is known to contribute substantially to both physical and psychological discomfort of the dying patient and great angst for their families. Research6 has shown that patients’ fear of abandonment may stem from contextual confusion, centered on their inability to grasp their situation or due to imagined barriers between them and their caregivers. Both dying patients and their families are usually highly sensitized and therefore very responsive affectively to both the verbal and nonverbal aspects of care tenor including subtle or subliminal7 cues of abandonment. As Dr. Rousseau states in his poignant pioneer essay8, even physicians themselves are defenseless against this cavalier treatment when we find ourselves to be on the receiving end.
Both dying patients and their families are usually highly sensitized and therefore very responsive affectively to both the verbal and nonverbal aspects of care tenor including subtle or subliminal cues of abandonment.
Fortunately, the times are changing and so physicians can safely break the dubious ancient tradition of abandonment of the terminally ill. While we can certainly take hope in the fact that the modern hospice and palliative care movement has made great strides in bringing the physician back to the bedside of the dying patient, we still have a long way to go before we can pride ourselves on being willingly and wholeheartedly present at the bedside. Until then primum non desero(first, do not abandon) may need to be practiced concurrently with the ancient medical dictum of primum non nocere.
1. McCullough LB: Words and word order count: The relationship between healthcare professionals and patients and our ethics teaching. (www.asbh.org/publications/pdfs/fallexch. pdf) (Last accessed May 10, 2007).
2. Jones WHS: The Art: Translation of Hippocrates II. Cambridge, MA: Harvard University Press, 1923.
3. Lascaratos J, Poulakou-Rebelakou E, Marketos S: Abandonment of terminally ill patients in the Byzantine era. An ancient tradition? J Med Ethics 1999;25:254.
4. Gavrin J, Chapman CR: Clinical management of dying patients. West J Med 1995;163:268-277.
5. Buckingham RW: Hospice and health policy. Health Policy Educ 1980;1:303-315.
6. Judkins W, Roberto KA: Abandonment fears of persons with Alzheimer’s disease attending adult day care. Am J Alzheimer’s Dis Other Demen 2001;16:247-250.
7. Kunst-Wilson WR, Zajonc RB: Affective discrimination of stimuli that cannot be recognized. Science 1980;207:557- 558.
8. Rousseau P: My journey. J Palliat Med 2007;10:867-870.
About the Authors
VYJEYANTHI S. PERIYAKOIL, M.D.
Stanford University School of Medicine, Stanford, California.
VA Palo Alto Health Care System,
Palo Alto, California.
Address Reprint Requests
V.S. Periyakoil, M.D.
3801 Miranda Avenue
Palo Alto, CA 94304