Sunday, January 13, 2008

How a doctor might tell you that "you are dying."

Which is worse... telling a patient directly "you are going to die," or having them leave your office having no idea because you tried to phrase it gently?

While I haven't yet been trained in breaking bad news to patients, the answer to this seems like it may be fairly obvious.

In an
article published in the Journal of Clinical Oncology, author Scott Berry tackles this issue. Most interesting is a role-play situation in which physicians had to tell a patient they were dying; only one of eight oncologists used the word death. In the name of empathy and gentleness, perhaps the following statements veered too far into the realm of vague:


What the physicain said: Most people with this disease will have problems soon...Time could be very short—a few weeks to a few months. I think it is advisable to prepare for the worst and hope for the best.
What the physician meant: You are dying.

What the physicain said: Your time may be short.
What the physician meant: You are dying.

What the physicain said: If there were a hundred people in your situation, most of those people would have major problems within one month or so...let's consider that we are now at Labor Day. By the time we get to late September, early October, I would expect that you would be having major challenges or problems.
What the physician meant: You are dying.

What the physicain said: Certainly, it sounds like the disease is really threatening your life.
What the physician meant: You are dying.


4 comments:

adventures in disaster said...

I have even better one.
The cardiac surgeon came into the unit found me and asked me to get the patients family in the quiet room. For twenty two minutes this surgeon intricately described every move he made during the surgery up to and including the fact that both sides of the heart had come apart and he was unable to repair it. He then said nothing. It was up to me the RN to explain that their mother had died on the table.
He just nodded as I told them then he got up, shook everyones hand and left.
The family was in shock and inconsolable.

In ten years I do not believe that man ever told anyone that the patient had died.

Ghetto Medic said...

As a a paramedic, it's rare that I tell someone that they are going to die. In fact, I don't ever recall explicitly telling someone that their death was coming in any time window. It's just not within the scope of my practice to make a prediction such as that.

I have, however, told people that their family member or friend is dead. I usually take the blunt approach. I figure it is better to err on the side of clarity than euphemistic bullshit.

It really doesn't matter what you say so long as you make it clear. Once you say, "They're dead." Everything else you say subsequent to that will be forgotten. So if there's really important information you need to convey, say if before you tell them about the death.

In cardiac arrest situations, I do my 20 minutes of ACLS, then pack it up if the patient is still asystolic. This is the most common scenario when I talk about death. Trauma deaths, like shooting deaths, DOAs etc, are usually not as hard. People seldom die in the presence of others who care about them. When someone is shot dead in the street, few of the people who cared about that person remain on scene, usually due to some complicity in their part.

But back to the cardiac arrest.

You need to prep the family first. Paint a grim picture. That needs to happen a few minutes prior to breaking the news like this, "Right now, your husband hasn't responded to any of our medications or procedures. We're performing CPR to circulate blood in his body; I've placed a breathing tube in his throat and we're breathing for him with oxygen. I've given him powerful medications that have had no effect."

Then, when you reach the 20 minute mark, and if the family has no objections and it doesn't seem like they'll kill you for not saving their loved one (as in the "if he dies you die, bitch!" speech which you sometimes get.), then I finish with this speech:
There's nothing more that can be done. We've have done everything medically possible. We have done everything the hospital would do. There is nothing else we can do. Your husband has died. He is dead. I'm very sorry. I know this is probably very confusing for you. What can I do to be helpful?"

That last question is key. You need to ask family how you can help them. They're now your patients, really. Your initial patient is dead. Most people have questions like, "What now? What do I do next?" Then you direct them to the police, in my case, who may look over the scene for suspicious circumstances, determine if the ME needs to come out and investigate. If not, then a funeral home or deputy coroner will come pick up the body while the family waits with the police.

Always pick up your trash, always cover the body, and always tidy up as much as possible. Try and leave the house in the way you found it. And always save any comments about the call or any unrelated conversation until you are 100% sure that no member of the public or family will see you or hear you. Laughter and criticism is not okay until you're 4 blocks away from the call in a locked ambulance.

The thing that most people really like is when you give them a box of tissues and warm cup of coffee. They don't need a lot of talk. Just simple things. Nobody has ever turned down the tissues. Men in particular. They often have a hard time being emotional in the presence of other men. So the tissues help them dab away tears discreetly.

And the coffee makes people feel comfy. It's something warm and reassuring they can hold in their hands. It gives people something to focus on and something to occupy them.

So that's my two cents.

CountyRat said...

Ghetto Medic, your post should be printed in textbooks. You have it right from start to finish. I only comment here to add one point, which is apparent in Ghetto Medic's post, but not stated overtly. You cannot do anything to change the fact that this is going to be the most horrible moment in a fellow human beings life. I think that were we often go wrong is that we think that if we just choose our words with sufficient care and delicacy, it won’t hurt so much; them, or us. Wrong. It will be agonizing however you say it. So say it. Don’t flatter yourself. At this moment, you are insignificant. You don’t matter at all. Don’t try to matter. Instead, do this: be there. Stay with the person. You do not need to say anything more, because nothing that you say will matter. Answer questions and respond to them, of course, but keep it simple, and do not delude yourself into thinking that you matter or anything that you say will make them feel better. They are not supposed to feel better. Their job is to feal worse than they ever have in their lives. Your job is to accompany them on that dreadful journey until someone else can take over. Just stay there with them.

“But,” I hear you ask, “what do I DO while I am there?” Simple. You suffer. You stand or sit there, and suffer with them. No, you don’t go to pieces; of course not! You must be professional. They need you to be a point of stability for them. However, days later when they start recovering, they are not going to remember you or your words at all, which is fine, because you do not matter at all. They may, however, remember that in the worst moment of their life, a caring person stayed with them and suffered with them, rather than condemning them to suffer alone.

Not so complicated, is it? Just very, very painful. Why should it be otherwise?

Vitum Medicinus said...

Thank you so much for using this as a place to dump advice from your experience... of which I have very little (okay, zilch) in this area. I am absorbing it all like a sponge and will undoubtedly make use of it when the time comes!