Balancing honesty and optimism in critical care

Balancing honesty and optimism in critical care

A recent little essay entitled “Do patients bond best with doctors who misinform them with optimism” got me thinking about balancing honesty and optimism in practicing any medical specialty in which patients not infrequently die.

Tragic things can happen in the pediatric intensive care unit. Anyone who works there — doctors, nurses, respiratory therapists, and many others — see these tragic things. Children are there who are seriously ill or injured, and some of them die. I’ve been practicing pediatric critical care for 30 years and I long ago lost count of the number of children I’ve seen die in front of me. When I meet someone new and they find out what I do they often ask me how I do it, often adding that they never could. More than a few of these people are physicians. My answer is that I don’t really see the question in the same way that they do.

For one thing, tragic things happen whether or not I’m personally there to see them. Tragedies are a part of life, and I have the privilege of participating in that aspect of life. The experiences I and my fellow intensivists have in our work are now unusual, but once they were common — they were shared among most adults a century ago. So, in a way, what I participate in with a child and the family has been usual for far longer than it has been unusual. That’s what I mean when I say that participating in these human events is a privilege. It really is.

I am an optimist. Even when the chances of a child’s good outcome are long, I can still proceed optimistically. I can even show my optimism to the child’s family. But, of course, I must also be honest with the family — if the situation is dire, I need to tell them that. But I don’t think those two things are contradictory. I don’t think I hold out false hope, but I do tell families that I’m hopeful.

This way of practicing goes against a common technique of PICU practice, one which many call “hanging crepe.” The idea is that the doctor can be hopeful and optimistic with families until the outcome begins to look increasingly ominous. At that point, to prepare families for the probability of death, the doctor becomes progressively more pessimistic with them. I think that approach underestimates the ability of families to discern for themselves that things are not going well –  nearly all do. (Like everything in medicine, there are exceptions. In my experience, families who have trouble with this approach are already highly dysfunctional or have parents with their own cognitive issues.)

In essence, I think most families easily adopt what is really the common sense approach humans have used for millennia in the face of critical illness: realistic about the chances, but still optimistic. The physician’s job is to tell families (and children) what we know about the chances, but there is no reason not to remain optimistic, too.

Christopher Johnson is a pediatric intensive care physician and author of Your Critically Ill Child: Life and Death Choices Parents Must Face, How to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

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  • Observer

    I would strongly encourage you to revise your practise and ask that you verbalize what you think the family is supposed to be surmising on its own Having recently gone through the experience of caring for someone with a severe burn that ultimately proved terminal, we had our suspicions about her ultimate fate but were never able to get any of her medical team to come out and state the facts. We would have made different choices earlier for her medical care had we been told just once that she was not likely to make it. As it was, with our readings of the medical literature unconfirmed by her medical team, it was not until it had reached the point that we felt like we were torturing her by lopping off various body parts that we had the certainty that what we read was still medically accurate that we needed to make the decision to remove her from life support.

    The families of your patients deserve the gift of your honesty.

  • Christopher Johnson

    Of course I’m honest with families. My point is that, for the broad range of patients, optimism and honesty are not mutually exclusive.

    Another thing I’ve found over the years, something that should be obvious and self-evident but is too often not practiced, is that spending time each day with families of a critically ill child lays the groundwork for ongoing discussions if things take a turn for the worse. You can’t create a trusting relationship without it.

  • Ferkham pasha

    Their are very good doctors out their

  • StephenModesto

    Thank you for sharing the synoptical perspective of your 30 years of practice in providing critical care. Yes, all life on the planet autonomically seeks to sustain its own pulse of vitality….And yes, there are millions of people/patients who do not have the opportunity to receive medical care when critically ill or injured yet the fact of `being’ in a critcal care unit does not intrinsically guarantee how the coin flipping in the air will land. The Holistic adjunct of grief counseling is indeed an important `customer service’ to be provided, but this aspect of the pt/family support system is not factored into the administrative budgetary restraints of billable services for more tests/labs/procedures under the guise of `optimism and hope’.

  • Taher Kagalwala

    I am a general pediatrician with some experience in managing intensive care patients too. I agree that one needs to inject a bit of optimism into the morning counselling session with the patient. At the same time, I fully endorse the view that parents most often have the instinctive feeling that their child is taking/has taken a turn for the worse and it is therefore essential to be honest and give out the truth. Thanks for sharing this with us, Dr. Christopher.

  • katerinahurd

    Do you think that your optimism provides you with an invisible shield that makes your fellow physicians wonder about your ability to treat children in an ICU? How do you see the transition between optimism and hope.

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