The Right Wrong Choice

I’m not the world’s most flexible person. I like black and white answers. When I ask a question, I want a firm answer. I can take and give hard truths. It’s not always easy but honesty is such a gift that knowing where you are in your health, in your personal and professional life is worth the emotional toll.

At first glance, the medical field seems like an area that would be cut-and-dry. Either you need surgery or you don’t. Either you have cancer or you don’t. It can be that way. Certainly in the area of diagnosis, it’s pretty much a yes or no type of situation. But in almost every other area, you find complications.

One great example is a patient I was seeing who due to numerous abdominal surgeries, had a phenomenon known as short gut syndrome. This condition means that a person does not have enough of their small and/or large intestine to adequately absorb the nutrients needed to sustain life. In this case, my patient was on parenteral nutrition or TPN.

Parenteral nutrition is not without its risks. Because you’re delivering nutrients into the bloodstream, you’re providing a potential source of infection and this was the case for my patient. The patient had experienced several severe infections and our infectious disease doctor wanted to discontinue the TPN and ultimately we did.

When we stopped the nutrition support, I worked to maximize oral intake with supplements, soft foods, small frequent meals and anything else I could provide. Soon after stopping the TPN, the patient began to lose weight. While the infection was improving, we began to see malnourishment appearing.

Hard Choices

Ultimately, I’m not making the decision for this patient. I make a recommendation to the doctor and follow along but I didn’t have a great recommendation for this patient. Sure, we can start the TPN after the infection clears, but she’s already had several infections and will likely have more with ongoing nutrition support. I’ve discussed the case with my co-workers and six highly trained dietitians don’t have a great answer.

This example is just one of many. How many times do we struggle to choose the best of bad choices? Our patients and their families are frustrated by our lack of answers and I don’t blame them. I’m also frustrated. At some point we have to accept that there are limitations to the healing power of nutrition and there may not be one “right” answer.

Inevitable Denial

In a case where you have two good options, you may spend some time considering your decision, but ultimately you will choose one of those options. However, in the case of two bad choices, patients and families are paralyzed. They don’t want to choose either option so they simply decide to not make either choice.

One example, is a patient with a diabetic foot wound. The podiatrist states that if the wound is left untreated, the patient will develop sepsis and likely die. The life-saving option is to amputate the leg, ridding your body of the infection. For the doctor, there is a good and a bad choice but the patient sees his choices differently. He sees a lifetime of navigating life with only one leg. A lifetime of limitations and “disability.” A lifetime with a decreased quality of life. How can he make the choice? He forgets that there is a deadline on his decision and waits too long. All of us in the medical field have seen this happen.

Encourage Speed

The only practical advice I can give dietitians is that you need to encourage quick decision-making. In the medical field, speed is your friend. If you have an infection or a wound or almost any other condition, waiting is only going to make your bad situations worse. As a team, we should encourage thoughtfulness but also work with patients and families to set deadlines on these decisions. I’ve had doctors explain that we’ll make a choice by X-date and then stick to it. While families often struggle with being given a deadline, taking either choice now works out better than doing nothing for weeks or months.

Final Thoughts

We can’t make these decisions for our patients and I certainly don’t have all the answers. We can help our patients and families by working with our medical teams to provide the possible choices, explain each one, and then discuss a timeframe for making those decisions. This doesn’t fix my TPN problem and it won’t work for every situation. Best of luck to all you dietitians out there!