Out of adversity, gifts of learning.

In the course of my career, I’ve unfortunately had many occasions to deliver “bad news” to patients and their families. This usually involves making them aware that treatments are either not working or no curative options are available, and that the end is imminent. In these moments, reactions are personal, individual and usually unpredictable. No matter how much one rationally anticipates the end of life, the actual reality can never be fully prepared for. The responses are raw, without pretense or veneer. As physicians delivering such news, we’re never truly prepared, and never feel adequate to the task.

I particularly recall an occasion when I participated in delivering “bad news” to a patient I’d been following for many years through several cardiac crises and surgeries. Together with two of my colleagues also involved in his care, and a number of involved students and residents, we informed him, his wife and teen-aged sons that, despite the fact that he was only in his mid 50’s, there were no options any longer available to treat his severely damaged heart and that he had only a short time to live.

There is no truly good way to deliver “bad news” to a patient. There are, however, a number of very bad ways to go about it. My experience and readings would suggest a number of key considerations:

  • Clarity is a virtue. The use of euphemisms or expressions of uncertainty about the outcome just increase anxiety. If we’re not sure, we shouldn’t be having the conversation.
  • Patients appreciate hearing bad news from someone they know and have come to trust. We should try to have such people involved, even though current patterns of practice make this difficult.
  • Patients don’t usually need or desire detailed medical descriptions of why treatments have failed, but once they realize the outcome is certain, will have very practical questions about what will happen. How long? How will it happen? Will there be pain?
  • Patients are often more aware of the realities than we anticipate. They are, after all, experiencing the success or failure of treatments. What we’re telling them is often much less of a surprise and we’re really confirming their impressions.
  • Patients need to know they will not be abandoned. We need to express the ongoing plan for management.

I was anticipating all this when we spoke to my patient.  I was ready for anger, disappointment, denial and all the other responses we’re taught to anticipate and I’ve seen before. I was not, however, prepared for his reaction. Sadness, to be sure, but his first response was to thank us. He shook our hands. Incredibly, his only question was whether any of his organs would be suitable for donation.

Physicians have recognized for many years that our patients are our best teachers. For the most part, this relates to what they teach us about medical matters. What’s less apparent is that they also have the capacity to teach us so much about the human condition and the human spirit, at its worst and at its very best. We have the privilege of sharing life-altering experiences and witnessing not only the suffering, but also how people are able to summon incredible reservoirs of strength and generosity of spirit in times of apparent hopelessness. It’s simply inspiring. That day, in a few moments, that patient, with a few gestures and comments, provided invaluable gifts of learning, not only for myself and my colleagues, but also for the nurses, residents and students in attendance. Perhaps most importantly, he provided an inspiring example for his young family. Out of his adversity, those gifts of learning will affect other patients and other lives.

By the way, I’ve since signed my organ donor card.

 

 

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

8 Responses to Out of adversity, gifts of learning.

  1. Wow, what an incredibly powerful post Dr. Sanfilippo. Thank-you very much for posting this.

  2. John Jeffrey says:

    Tony. An inspiring piece that highlights what is important. This is coming from someone, who like you, deals with these issues on a regular basis. Well done! John Jeffrey

  3. Ray Viola says:

    Tony:

    Thank you for this blog. I facilitate a session in Term 4 Clinical Skills called Difficult Conversations, during which students practice a model for delivering bad news. I inherited this session 3 years ago. The students universally find it extremely useful, largely because of the efforts and commitment of the standardized patients who take part, but also because the students recognize that this is an important communication skill that they will use no matter what field of medicine they practice. It’s also a skill that doesn’t go out of date; in fact, we get better at it as our experience grows (I hope I have, anyway). I have aspirations to explore creating our own local learning tools (videos and modules) for this and other difficult conversations (I currently use Robert Buckman’s videos, although the model we use was developed at Queen’s). Ray

  4. Mason Curtis says:

    Great discussion. I think one of the many key aspects that stand out from this story is the importance of clarity. From both the delivery of such news, but also (and arguably just as important) clarity throughout the duration of providing patient care. By giving the patient and their family a clear understanding of what the medical team is thinking as each day progresses it may help ensure both parties are on the same page. In doing so, when the time comes to deliver such news, the patient is fully aware each step of the way that options had been explored, colleagues had been consulted, imaging studies have been completed and results discussed. This is easier said than done, as I have enough difficulty at times keeping up with the medical language after an undergraduate degree in sciences and 3 years of medicine, how can we expect patients with no background in the field to do so? This essential skill of becoming a “medical translator” is difficult to teach in the classroom, textbook or simulation lab, but is honed through experience, both positive and negative ones. Though I have no objective evidence to support it, I would bet that providing clarity to patients help tip the scales in favour of both the patient and health care provider. Thanks for the great post.

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