I got a page from the nurse: “Dr. Alice, do you think you could come see Mrs. X? She’s very anxious, driving herself and us up the walls. She and her family are demanding to talk to a doctor about her condition.” “Her condition” being metastatic cancer. Sure, I would love to come talk to her.
I took a brief detour past the computer to review what I thought I knew about her cancer. Yes, very short life expectancy. Yes, very unsuccessful treatments. Yes, only a few experimental trials. Great.
We found an empty room to sit down in, and talked. Fortunately, a lot of it was her just wanting to talk about how miserable she’d felt, and how we’d neglected some of her needs. Which we had, so I apologized, and straightened things out with the nurses. But finally, she and her family started asking about what treatments were available, and how soon they could start. I got through it somehow, mostly by promising to go get a more definite answer from the attending; that was one question I wasn’t too afraid to ask him, since he’s very gentle and careful about his cancer patients.
At one point they did ask something about prognosis, and I made some kind of statement involving the phrase “metastatic cancer.” I knew the attending had talked to her family right after surgery, and to her the day after. I assumed he’d used those words, since everyone on the team had known it from the moment the incision entered the peritoneum. Nope. There was a blank look on their faces, and I backtracked hastily. Fortunately (this time) I tend to speak really fast under stress, and sometimes pretty softly. I think most people in the room missed what I said, except for one son who looked far more enlightened than I could wish. . . I asked what the attending had told them, and then stuck to his phraseology: “a little too large to remove with surgery.” I should just play dumb more often. Just because for once I did know the answer, doesn’t mean I have to show off by giving the answer.
I hate being the intern, totally ignorant about prognosis and treatment, being the one available to discuss all this with the family at the time that they’re all visiting on the floor. I hate being in the dark about what the attending said and what his plans are, and being left to trip through minefields, damaging the patient’s morale and their rapport with the attending. I hate cancer; and I really hate metastatic cancer.
Mrs. X is a Christian, I believe. I have prayed with her, just about recovering from surgery. I think it would count as undermining the attending’s plan if I tried to say anything comforting about death itself, since he doesn’t want to go there with her yet.
August 24, 2007 at 7:09 pm
At what point does honesty enter the picture and who is first tasked with that in patient care? And, what happens when that person shirks their responsibility?
I ask, not as a challenge to you, or as a criticism, but as someone (52 years old) who’s at that time of life when uncles, aunts, parents, parents-n-law, grandparents and other elders in my circle of kith and kin are in the final stages of life.
And as someone who’s lost people long before their alloted three score years and ten.
I’ve become adept at reading between the unspoken words. When patients start being avoided by both doctors and nurses, when patients are sent home – without anyone ever stating/admitting that all that can be done, has been done.
I resent having to guess as to what is happening, rather than being told outright what is going on. Inevitable news I can handle, ambiguity is unnecessarily obscure.
Are there established protocols that kick in in more compassionate care facilities… and what are they?
My hat is off to all in health care, it’s a job I could not do, I’d take each case too closely to heart and would run out of all compassion within a month. It would break me.
In peace.
August 26, 2007 at 3:46 am
What can I say? Obviously I disagree with the attending’s approach, but at the same time, I can see his point. Most of these elderly patients are tremendously stressed already by having had a huge surgery, being in the hospital for 1-2 weeks, and facing the prospect of another few weeks in rehab before they can go home. Perhaps it’s true that if they were told up front that they had metastatic cancer, or that the margins had been positive, they would lose whatever will to live they have left, and give up and die, or at least not recover, and thus lose what quality of life is still available to them, if they are able to spend at least a few more months or weeks in their own homes.
If by compassionate facilities, you mean hospice and palliative care – yes, we’re very active at referring patients to hospice – when things are inevitable. That is, when the cancer has clearly recurred or metastasized, and there is obviously nothing else medical that will significantly prolong the patient’s life; then the attending is very willing to set the patient up with hospice. But he just doesn’t want to discuss that possibility during their recovery from surgery.
August 26, 2007 at 10:05 pm
Someone in the family may have picked up on what you said. That person doubtless knows the patient better than you — and likely better than the attending. Hopefully, that person will be blessed with the appropriate level of tact to share (or not) what you revealed.
As technobility suggests, someone – perhaps the patient – was already reading between the lines. You may have only confirmed what the family already suspected.