Aggressively pursuing a diagnosis may lead to worse outcomes for some patients, suggesting a “stop and think” approach is beneficial in some cases, according to a correspondence published in the American Journal of Hematology.1
Nearly 30 years ago, the US National Academy of Medicine (formerly the Institute of Medicine) stated that any medical intervention should lead to more benefits for a patient than negative consequences, and that the difference should be of a sufficient margin. While clinicians aim to maintain this margin, there are cases where it is unclear whether any intervention — including pursuing diagnosis — is more likely to yield benefits than negative consequences.
In the present correspondence, the authors recount the case of a patient whose family insisted that he receive a series of diagnostic tests for cancer, even though, had a malignancy been found, the patient would likely not have been fit for any clinical intervention.
Cases like this raise significant bioethical questions, notably as to whether it’s correct to pursue a standard diagnostic routine in cases where a correct diagnosis is unlikely to be clinically useful to the patient in question. Whether aggressively pursuing diagnosis in these cases retains the margin between benefit and consequence is, unfortunately, often unclear.
The authors noted that while clinical intervention futility — the low likelihood that a treatment will be effective — is often considered, diagnostic futility does not receive the same level of consideration in the clinical setting. That a diagnosis itself may be futile is clinically relevant — even considering that patients and their families may feel some relief at knowing what the ailment is, regardless of its implications.
The authors suggest that a diagnostic utility/futility scoring system be developed, to assist clinicians when it is unclear whether aggressively pursuing diagnosis will be beneficial.
“How to identify cases most likely to benefit from a diagnostic momentum-interruption is difficult,” they wrote. “Until machine learning technologies point us in the right direction, a simple ‘pause and think’ intervention is likely to be the wisest strategy.”
Oren O, Kyle RA, Steensma DP, et al. Recognizing “diagnostic futility” – stopping earlier to protect patients [published online March 16, 2020]. Am J Hematol. doi: 10.1002/ajh.25786