June 17, 2002
Redefining Failure: A Nurse's View
Teresa T. Goodell, RN, MSN, CCRN, CS
Cancer patients whose therapies have not succeeded are said by their physicians to have failed therapy. When chemotherapy doesn't stop the spread of a tumor or when radiation can't control metastasis, the patient is reported in cancer conference to have failed treatment. Many cancer patients have heard the failure word, and many use it to describe their treatment history, as if it were a fact of their illness course. One young woman with breast cancer told me, "I failed chemotherapy, radiation and surgery," as if it were a test. (A test of what?)
Physicians invest a great deal in the success of their treatments, even feeling personally defeated by treatment failures. They are trained to see death, decline and disability as enemies against which they do battle. The success of their many weapons in the fight against disease defines their competence as practitioners and the impact they have on their patients, whose lives many physicians hold dear. In short, despite attempts to maintain a degree of healthy objectivity, they come to see treatment failures as their own failures because they are operating more as generals in an army than as partners in an intimate human interaction, that of patient and provider. Perhaps it's different for nurses because we aren't held personally responsible for the patient's disease course. Perhaps it's easier for us to accept failure as inevitable in certain cases and move on to deal with the consequences of this failure, in terms of symptom control and psychosocial needs, keeping our eyes on the holistic picture. In this regard, nurses are fortunate. Nonetheless, physicians could learn a great deal from reconsidering the assumptions underlying their use of the word failure. These assumptions deserve questioning.
First, if death, decline and disability are defined as failure, how is success defined? Immortality? Extraordinary longevity? Cure? A pain-free death? A death that imposes minimal burden on patient and family ? A death that occurs expectedly after a chronic illness, rather than suddenly? A death that occurs suddenly, unaccompanied by a prolonged period of decline and disability? The fact of death, is of course, universal. But its timing and trajectory are often uncontrollable. Many people are diagnosed with cancer at the point where treatment will not cure them and may not extend their lives. In these people, decline and disability are inevitable. In defining death, decline and disability as failure, physicians risk relegating certain patients to a mental list of those whom they would rather not think about, preferring to concentrate on those who present them with opportunities for success. This attitude fuels the underdeveloped state of palliative care, and robs physicians, whose priorities direct health care, and other health care providers of opportunities to make tremendous contributions to the care of patients with terminal illnesses.
Second, if a patient is said to fail a treatment, who is believed to be serving whom? A therapy exists to serve the patient, and, indirectly, the provider, not vice versa. The patient is not responsible for the treatment's reputation; the treatment and the provider are responsible for the patient's well-being. I make it a practice to gently correct patients who report that they failed therapy, saying, "No, the therapy failed you." Even inadvertently suggesting that failure is the patient's fault is irresponsible, and can only compound the suffering of the patient.
I propose that failure be redefined by our medical colleagues to signify non-achievement of mutually agreed-upon treatment goals. These goals may mean cure, symptom control, life prolongation, or preparation for death, among others. They may include family members and friends. They may include cure and non-recurrence, if it is achievable. Regardless of the specific nature of treatment goals, they must be agreed upon by patient and provider. Then failure could be seen as a failure of the treatment plan, not failure of the provider or of the patient. Redefining failure will help physicians and patients act more like a team in designing treatment plans and mutually negotiating goals. More importantly, it will help eliminate from medical language the notion that patients fail therapy, an idea that is damaging to patients, to health care, and to providers.
Teresa T. Goodell, RN, MSN, CCRN, CS
Clinical Nurse Specialist
Oregon Medical Laser Center
Providence St. Vincent Medical Center
9205 SW Barnes Rd.
Portland, Or, USA 97225