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Painful truths

Posted on 22 November 2012 by Aoife Abbey  6 comments

‘I’ll be OK, won’t I? This won’t shorten my life?’

I went in to see her after I knew she had received a visit from the oncology team to break the news. She was a young woman with a glioblastoma.

To tell or not to tell?

I had found out the histology the day before. I was not aware my behaviour had changed in any way. She asked if I was OK, and said I seemed different. I feigned tiredness and changed the conversation; she had asked me the question I did not want to be asked.

My head said the five-year survival rate for glioblastomas was 6 per cent. Did she really want the truth? It was hard to decide in that second. What would I want?

I think I would want to know the truth, but would it be right for me to dash her optimism? Was I sure enough that she was one of the 94 per cent to remove from her that hope?

She repeated her question, adding: ‘If I’m wrong, I’d rather know now while it’s just me here.’

I explained to her I was not an oncologist but I knew she had a high-grade tumour and there were positive factors; she was young, fit and had a clear plan for treatment.

I said if she was an older woman with multiple co-morbidities, I might give an optimistic prognosis of one year but with her it was not clear cut.

I did not know if the tumour margins were all removed, I could not tell if it would grow back, and I did not know how she would respond to the treatment regimen. ‘But yes, there is a very real chance that this will shorten your life,’ I said.

She seemed content with this explanation. I sat with her for a while longer and we spoke about how upset she felt that she had brought this worry on her family.

I sympathised and told her that she could not stop her family from loving her and it was their prerogative to do so. I said that I hoped she would in time be able to free herself from the burden of feeling responsible for their pain.

Had I answered her questions truthfully? I had not lied. There was a real chance this would shorten her life. I wondered if I was wrong to alter the perception that she had been given by the oncology team.

Perhaps she did not ask them this question directly. She had chosen to ask me, and I think I would maintain it would have been wrong of me to lie.

Oscar Wilde said ‘the truth is rarely pure and never simple’.

Aoife Abbey is a foundation doctor 2 in neurosurgery in the West Midlands

Posted in:  Education and training Communication skills

Tags:  junior doctors medical education and training medical oncology cancer

Comments

  • Andrew Gilbey

    25 November 2012

    What you tell a patient and what the patient hears are two different things. As Oscar Wilde says ‘the truth is rarely pure and never simple’.

  • eric watts

    3 December 2012

    I think you did very well
    Communication is a complex, 2 way process - you need to consider not just the message you give out what they understand - it can can along time.

    When a patient asks a question in this situation they are often anxious and uable to absorb detail - what they often remember is whether you were empathetic - in which case they're likely to regard you as helpful & ask you more - or if you're not - ie evasive or too much detail

    Most importantly - go back next day & ask if there's anything they want to discuss when they've had a chance for information to sink in

  • Anne Sutcliffe

    4 December 2012

    I think you did well. You did not lie but you did not take away all hope - your patient does have a small chance of surviving more than five years. Sometimes it helps to break bad news in stages. You did not have the opportunity to prepare yourself or your patient for her diagnosis but she chose you as her informant. Perhaps she sensed your unhappiness about her diagnosis and that you were sympathetic to her needs. If you can stay in touch with her over the next days and weeks and build a rapport with her, eventually your conversations will inform her of the whole truth. If this isn't possible, tell the oncology team what she knows already and what they need to tell her in the future.

    At this stage in your career, breaking bad news is not something that you can be formally be taught and you lack the experience that will help you to deal with these situations, now and in the future. I encourage you to take every opportunity to watch more senior colleagues break bad news. Not all of them will do it well but with the sensitivity you have already demonstrated, you will be able to learn from the best and appreciate how not to do it.

    Breaking bad news never gets easier for us but with experience, we can make things easier for our patients and their families. You have a lifetime to learn these skills and I am sure that with greater experience you will do well.

    PS i am a retired consultant intensivist who worked in the West Midlands. I wish we could have worked together.

  • Patrick Xavier rtd radiotherapist

    4 December 2012

    I too think you did well on the information given, most certainly at this stage in your career! More accurate prognostication is up to the seniors. (Also, there for example are some patients who press you hard, but who really don't wish to know; others who have great responsibilities and who need to be told what the score is.) Provided you know your limits - and I strongly suspect that you do -
    then there should be no problem about referring this most difficult type of problem to seniors. Inter alia, useful allies in this type of situation can be experienced nursing staff, despite recent headlines.
    Your are certainly sensitive to patients' feelings; that will take you a long way. Good Luck!

  • Ray Parsons

    4 December 2012

    Dear Dr Abbey

    What a difficult task. I can recall being in similar situations many years ago when I worked on a neurosurgical unit.

    Having lived through this situation both as someone who had Hodgkins disease (which the textbook I was studying at that time said was a sentence of death) at the same stage of my own career, and as the father of a daughter with advanced ovarian cancer who died after chemotherapy I can empathise with both your situation and that of the patient.

    Whilst I agree with all the above comments, this is a job for the more experienced doctor. In your shoes, If I were now in your shoes I would have discussed this patient's situation with my consultant before speaking with that patient and be guided by his advice. Did you have the necessary senior support ?

    I think it would help also if you sat in with him whilst he spoke to the patient.

    Also, it is worth getting a relative/husband, or someone to be present to support her after she received the bad news.

    Too many junior doctors at your stage are put in difficult situations which at that stage of their careers are beyond their experience.

    It may help you to spend some time with a palliative care team to gain further experience and additional skills to cope with this situation when you meet it again, as I am sure you will regardless of whichever specialty you eventually choose.

    Some palliative care teams have flexible arrangements which allow trainees to allow them to spend a few months working with them to gain additional skills that every doctor needs throughout their careers.

    Best wishes for your future. As those above have said, you are a kind empathetic and caring doctor.

  • Marian Langsford

    5 December 2012

    Dear Dr Abbey,

    Thank-you for sharing this story.I agree-you handled it very well.
    I am interested that the patient chose to address the question to you and not the oncology team.She felt safe with you.I suspect you had already shown yourself as approachable prior to this-but your demeanor that day revealed that you cared about her and that gave her confidence to talk to you at a heart level.You responded by 'putting yourself in her shoes' ie empathising-and that enabled you to set the level of your response as well as afterwards recognising and starting to address the ensuing grief emotions of denial and guilt.
    In their book 'Intelligent Kindness', John Ballatt and Penelope Campling emphasise the importance of a good therapeutic alliance in outcomes as well as patient satisfaction and show that 'kindness,communicating fellow feeling and warmth,attentiveness to patients as people,and expressed through actions attuned to their suffering and needs' is strongly assocated with both satisfaction and outcomes.
    Taking the time to sit with your patient will have had an unmeasurable but highly significant therapeutic effect on a truly holistic level.
    Best wishes for your career-whatever you do dont forget this patient.

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