Many providers enter medicine to comfort patients and their loved ones. However, much of what I do doesn’t live up to that intention. In the past few months and particularly the past few weeks, I’ve spent most of my afternoons making little difference in the course of my patients’ hospital stays, and instead of having multiple conversations with the loved ones of these ill patients, providing daily updates, reiterating expectations for prognosis, and visiting goals of care. As a medical student, I evaded difficult conversations and deferred the delivery of frightening, unwelcome news to the real doctors on my team. I wanted to be a positive force in the patient’s hospitalization. In the first few months of residency, I instinctively shrunk back when the moment arose to inform loved ones of a patient’s deterioration: “We don’t believe that she will make further neurological improvement, or your mother may die tonight.” I would hover by my senior to see how the information was delivered. Delivering bad news does not carry the same catharsis of gratitude or relief as a conversation about patient recovery or improvement; however, there is a different emotional investment in the conversation. The heaviest are my conversations about patients who have experienced a complicated course or irreversible and catastrophic insults, setting them on a declining path that medical therapy cannot change. It is hard for loved ones to understand the course of events and accept discouraging expectations. It feels uncomfortable to impress the same dismal words repeatedly when these loved ones ask the same questions: “I don’t understand why or why this is happening now?” I might reiterate the same conversation daily with family members because the truth can be so unpalatable to grasp. Occasionally, loved ones even evade my communication in what I assume is paralysis of fear or indecision. Even seasoned physicians struggle with helping family members come to terms with the prognosis and limitations of medicine. Yet, we must pursue these conversations regardless. From my limited experience thus far, a family member has never answered my call and said, “Sorry, can you please call back at a more convenient time.” If I am calling during my work hours, the receiver is likely also at work and putting aside other tasks to hear the message. The update or explanation I give might be shared amongst multiple loved ones that day. Sometimes, after I break upsetting news to a hopeful recipient, the reverberation of that impact will ricochet back to me. Another family member will call to hear the information for themselves because so-and-so heard such terrible news from the doctor and is devastated. I hope that the meetings and calls benefit these loved ones, who are often burdened with terrible decision-making responsibilities as they watch a friend or family member decline. Health care proxies and next of kins may feel cornered, making critical choices with a fear of regret if whole parties aren’t in agreement. I hope they can be as emotionally prepared as possible for realistic outcomes. Perhaps by bracing their expectations, we can minimize the pain they and the patient will ultimately experience. I wonder about the impact of these conversations after-the-fact. After some conversations, I questioned if the family perhaps walked away with unreasonable hope because I did not adequately convey the severity of the situation. Then after other conversations, I consider if I was too harsh and painted too grim an image for families already disheartened. With experience, I can hopefully achieve finesse in conveying both transparency and support in situations when medicine’s comforts and utility become limited in the last chapters of a patient’s life. Source
