Between cure and death a lot occurs. It has a name: plateauing. And in treatment it means: do nothing and for some diseases it’s the perfect therapy. Take the Zika outbreak. We now know that patients with Zika and accompanying paralysis, Guillain-Barre syndrome, seem to go through a plateau phase (three to 10 days). The problem for clinicians has been what to do during the plateau phase. But a recent raft of articles shows how doing nothing during the plateau phase is the best therapy on offer.
The phenomenon is not exclusive to infectious diseases. It holds true in emergency situations where we have been led to believe that urgent interventions are always necessary. Using the plateau theory, acute blood loss, after an accident, may be best left untreated because the outcomes in the plateau phase (seven to 10 days) are the same, irrespective of whether the patient is treated or not.
In our current system where activity is evaluated and reimbursed, doing nothing is almost impossible.
Attaining a state of little or no change after a period of activity or progress is not only related to the start of treatment. In cancer it is all about stopping treatment and not just in palliative care. When a cancer is not progressing and is on a plateau, halting treatment may be the right thing to do because we now know that cancers fight themselves; as the cancer cells compete with each other for resources. This happens after a bout of chemotherapy and the remaining sensitive cancer cells eat up the nutrients that would feed the few treatment-resistant cells. It is called a ‘treatment holiday’ – but is, in fact, anything but a holiday.
From a plateau you can go up, down, both or neither. But in our current system, where activity is evaluated and reimbursed, doing nothing is almost impossible because healthcare operates on a business model: activity = outcome.
And yet clinical decisions can make a real difference in the way healthcare is practiced if we use the plateau concept.
No direction is always better than the possibility of downhilling to death. So it shouldn’t come as a surprise that the term plateau first gained clinical relevance in cancer. In the clinical world it now it sits comfortably alongside common terms terms like ‘chronic’, ‘remission’, ‘stable disease’. Perhaps then, doing nothing is the best choice for the patient and a lesson for our health institutions.