Optimal treatment versus harm-minimization

Good medical practice involves working with our patients to try to achieve optimal outcomes in the face of illness or disability.

When patients are noncompliant the first approach is to try to understand the non-compliance. Clinical judgement will guide us as to how challenging, supportive etc. we are in attempting to achieve optimal management. 

However, there sometimes comes a point in the management of a particular patient where optimal treatment is unrealistic.  Patients might lack the resources, motivation or interest in achieving optimal outcomes. 

In such situations it is important to consider a shift of attitude from optimal treatment to harm minimization.  Goals are changed to emphasise how to avoid the most dangerous outcomes. 

A well known example of this strategy is the use of needle exchange programs for heroin addicts. Clearly optimal management would involve stopping heroin altogether, but because this goal is considered to be unrealistic, harm minimization strategies are used to avoid some of the worst possible outcomes. 

Similar principles can be applied in the general practice setting

eg. a patient who has been resistant to attempts to engage her in optimal management of her diabetes might be more responsive to 2 or 3 key daily activities that prevent the worst complications of diabetes. 

The goal is to keep the patient alive and relatively healthy for long enough that they will choose to take appropriate responsibility for managing their illness.