Maurice,
I will probably go into more on this topic later, but I believe the word, "miracle," used in the medical context, really only means a good result that is either better than hoped for, or unexplained. As we've seen so many times in the past though, today's "miracle," once the cause is discovered, becomes tomorrow's "standard of care."

Religious people are going to hope for supernatural intervention regardless of what we tell them is scientifically possible. By definition, that is the true purpose of a miracle. If we could take care of the problem with a known treatment, they wouldn't need one.

As for the advertisement you mentioned, it sounds like good marketing, and the use of the word, "miracle," is used there as "mere puffery." I doubt anyone actually expects them to invoke supernatural therapy, nor do I believe the use of the word will have any effect at all upon whether a patient has unrealistic expectations based upon the hope of divine intervention.

Beth, from a patient's point of view maybe the reason for "cure" or "not cure" would not be important to the patient but it certainly is important for the physician and his or her personal catalog of professional therapeutic experience. ..Maurice.

Eric, in the posting your wrote just prior to last on, you remarked "No, I would not urge, and would actively dissuade patients from mindlessly pursuing costly, potentially painful and futile therapy rather than helping them accept the outcome that, at least for now,awaits us all." And then yet next you write "If a belief in miracles brings solace and comfort to a terminally ill patient and their family, even understanding the disappointment that probably awaits them, I would not choose to take that away regardless of my own beliefs or the current state of our knowledge." How do you resolve the conflict of "not take away regardless of our beliefs or current state of knowledge" and yet you are "dissuading patients from mindlessly pursuing costly, potentially painful and futile therapy" when a this is what they feel would be the pathway for a miracle to occur? Can a physician present, both important and valid positions together to the patient and family as coherent professional advice? To me, the positions seem conflicted. ..Maurice.

Maurice,
My positions are not irreconcilable. Our job as physicians is to use our "superior" knowledge of medicine to cure if possible, and palliate when not. Of equal importance, though, and frequently forgotten in these discussions is our obligation to counsel our patients.

Faced with a patient or family in a position where further treatment would not only be costly (which would not, in and of itself deter me) but potentially harmful or painful and, ultimately futile, I would counsel the patient and their family to opt for quality of life, however short its duration. As Kim alludes to above, we have made the hospital bed the place where most people in this country die. They are surrounded by tubes and machines, and sometimes medicated to the point of oblivion. If I were in that position, I would want to spend the time I had left with my family around me, not strangers, however caring they may be.

Even when there is no alternative to an institution because of the severity of a patient's condition, it has been my experience (of which I have had more than my share as Medical Director of two long term care facilities) that many families cling to the hope for miracles less from an actual belief in them than from some inner sense of guilt as their loved one slips away. Was I a good son or daughter? Could I have done more for my husband? If only I could have a little more time with them . . .

Perhaps my experience with my own father can serve to exemplify my point. He had several medical problems that were not immediately fatal, but his cognition was rapidly deteriorating. He was in an assisted living facility because, even with "around the clock" nursing, he became unable to live in his own apartment and my mother had died several years earlier. After falling and fracturing his hip, he underwent successful surgery but, upon awakening, his mind had deteriorated to the point where he was disoriented and could no longer even remember I was there if I left the room for a few minutes.

At the same time, he stopped eating and drinking, leaving a PEG tube the only option for nutrition and hydration. I am an only child so the task fell to me, alone, to make the decision. I certainly wanted my father to live and to spend more time with him. Like most people, I rehashed mistakes I had made in my life when I could have been a better son or, perhaps, brought him greater joy. Ultimately, though, I saw that though the surgery was successful, his mental status left him unable to cooperate with P.T., and he would be doomed to spend his remaining months (my experience had taught me that it would probably not be longer) sitting in a chair, fed through a tube in his abdomen, and developing decubitus ulcers, infections, pneumonia and other inevitable illnesses while his mind sank even further away. It was not the way I would want to go, and not the way I wanted to see my father suffer. I refused the procedure and, shortly thereafter, he slipped quietly and peacefully away.

I would be lying if I said I never regretted my decision, although I'm sure it would be unchanged if I had to make it again. I would also be lying if I didn't question my own motives; was I doing it for his benefit or mine?

I was fortunate to have had the benefit of superior knowledge and experience to help me make my decision; however painful it was for me then, and even now. How much more difficult must it be for those without that benefit to make the same decision. It is our job to bring that wisdom, which I have heard defined as "knowledge tempered by experience," to our patients. We cannot make the decision for them, nor would I want to, but we can at least help them to understand that sometimes trying everything medically available in the vain hope of a miracle is causing more harm than good and, after all, isn't our "Prime Directive," Primum non nocere?

Dear Colleagues.

In the hand of a good doctor with good sense and consciousness, miracles will always exist. Regardless of viewpoint, religious or scientific. Because we treat the human being and being human need faith. So let's continue to practice good medicine which fortunately for us we'll just heal, for some will be miracles and others just lucky.

And before the universe and our "smallness" and ignorance, only the word God can explain our existence. So miracles do exist at present independently of science.

Hugs and good weekend.
Mario.

Mario, I want to remind everyone that through your skills and knowledge as a pathologist, you are able to perform some of the "miracles" we are writing about here. While your approach may not be strictly spiritual in action or intent, it is the pathologic diagnosis of a tissue specimen that can change a disease which is poorly treatable or untreatable and carries a fatal prognosis into one for which there is effective treatment now available and is associated with a more optimistic outcome. What appears as a "miracle" represents the correction of an erroneous diagnosis. We should all remember that "miracles" hang on the diagnosis and anticipated clinical prognosis. If these are in error, then the outcome may truly appear as a miracle. ..Maurice.