Kind and thoughtful words from a fellow physician colleague

I was sitting on one of the hospital’s nursing units having a difficult telephone conversation.  Anyone working nearby could have easily discerned the situation from my end of the call.

Patient’s family member wants to keep aggressive care going for a comatose, terminally ill family member against the best advice of the medical team.

Having never had to make such a decision in my own life, I am left to imagine how heart-wrenching it must be for the family.  But the ICU team and specialists caring for the patient are in agreement – this patient will not recover.  The only question is under what circumstances this patient will die.

I tried to hear the family’s wishes and concerns with an open mind.  I tried to compassionately share my opinion about the extremely low probability of any meaningful recovery.  The ICU team had hoped that my rapport with this family would lead to a plan to withdraw care and permit a peaceful death; their conversations with the family regarding plan of care had resulted only in increasing hostility. The family member I spoke with was similarily adamant.  The family will not accept any outcome short of a full recovery, I was angrily told.  They expect this patient to walk out of the hospital as he/she was before, healthy and vibrant.

Being shouted at, with the clear implication that my judgment is unsound and my caring most deficient, was unpleasant to say the least.  I hung up the phone and put my head into my hands.  A resident sitting at the work station next to me commented, “that sounded tough.”  I shared the brief details of the situation and my sadness at this patient’s fate of futile tubes, IV lines, and machines.  The resident asked some thoughtful questions about making end-of-life decisions, and we conversed for a bit.  An attending nearby commented, “sounds like the family’s just not ready yet.”

“It just feels like … if I could have found the right thing to say, the right way to say it, that maybe the conversation could have gone better,” I responded.  I didn’t mind the eavesdropping at all.  I had that deep, hollow feeling that comes into the pit of my stomach when a patient or family encounter doesn’t go well, and it felt good to be able to share even a little of that with trusted acquaintances.

I dutifully delved back into the electronic records of our current inpatient team, signing off resident notes, looking at new labs, checking my outpatient in-box.  I tried, unsuccessfully, to convince that deep, hollow feeling in my stomach to go away.  Several minutes passed, and my empathizers drifted off to their other tasks.

Or so I thought.  Another colleague had been quietly working at a nearby computer station.  He walked up to me and said something along the lines of “listen, I couldn’t help but overhear what happened on the phone, and I heard you beating yourself up about it afterward.  But, it sounds to me like you did the best you could.  I heard what you said to them, and it was totally appropriate.

“Some things you just can’t change,” he continued.  (How many times have I said that to residents or medical students?)  “You did the best that anyone could have done.”

The deep, hollow feeling began to lose its grip on my GI tract.  This colleague recognized my suppressed agony and perceived a responsibility to respond to it.  With just a few kind and thoughtful words, he helped me to regain perspective on the situation.

How often do we physicians, thoughout our day-to-day lives, suffer these little (and, sometimes, very big) hurts?  Sometimes we share them with each other, but sometimes we don’t want to bother anyone.  Sometimes we’re too ashamed at our real and perceived failures.

I am grateful, today, that someone recognized and responded to my little hurt.

Jennifer Middleton is a family physician who blogs at The Singing Pen of Doctor Jen.

 

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  • http://www.Neurology4MRCP.com Osama SM Amin MD, FACP

    Dear Dr. Middleton,
    How often do we meet such colleagues? You are blessed to have one!
    Regards…

  • http://www.nallyfamilypractice.blogspot.com Adam Nally DO

    Great post. Thank you.

  • weakanddizzy

    This is going on all over the country. As hard as we try many patients cannot recover from serious illness. In this modern era of ” medical miracles” expectations are high. Every one of us ( myself included) will die someday. As a society we need to re examine our national priorities as providing futile care to every patient whose family demands it will bankrupt our country.

  • soloFP

    How about a hospice consult?
    In a related manner, if families did not consider it free care, as most patinets have Mediare and a supplement that covers 100% of the costs in the hospital, families and patients might think twice about making a terminally ill patient a full code.

  • http://myheartsisters.org Carolyn Thomas

    How fortunate that in the midst of such a gruelling and exhausting interaction with this patient’s family, you had colleagues around who were not only available to debrief with you, but who were also proactive in reaching out. That is true humanism at work in the profession.

  • SmartDoc

    Good post.

    Never underestimate the effect of compassionate words and (hopefully) helpful insights you give to a distressed colleague.

    Trust me, that distressed colleague will be you one day.

  • Molly Ciliberti, RN

    Excellent post. When confronted with a similar situation (I was the primary nurse for a dying patient) after trying your approach, I finally said, “I’m sorry, but I can no longer take care of your grandfather. I have the option to do this and I can no longer continue to hurt him with IV’s, dressing changes, etc. knowing that I am causing him pain and fearing that his last thoughts will be about my hurting him.” Since I had cared for him for about 3 weeks they begged me to reconsider; they had a fantasy of him living to play with small great-grandchildren. It only took a day when I was no longer caring for him for them to agree with the primary physician to let him die in peace without all of the heroics and agonizing pain inflicted upon him (trying to keep him alive.) I guess doctors can’t do this, but I think it gave them a different perspective to see how much their desire for him to live for them actually hurt him.

  • Dorothy Green

    It is difficult to understand all the circumstances of the situation from the author’s account but I got the feeling that perhaps the family was getting a mixed message. You mentioned “low propability” of recovery while talking about the futility of life support measures. Low doesn’t mean 0.
    Also, I didn’t understand why such a conversation was taking place over the phone.

    There are families who, for reasons that can never be determined by the care givers, like guilt, income from the dying person, or religious reasons, that are not necessarily a matter of letting go. They may never come around. This has been the substance of end-of-life legality or TV docudramas we are all familiar with.

    You have no reason to feel so badly because of their callous behavior if you know you presented everything in a realistic manner.

    I like Molly’s approach and the hospice idea – then you know you have done everything and show your concern for the patient while still empathizing with the family.

    The cost of end of life issues has to be a totally separate discussion.

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