In the middle of a fulfilling career as a reconstructive surgeon, I decided to change paths. I realized that I had become more interested in hearing my patients’ stories and helping them through the health-care labyrinth than in performing operations. This interest compelled me to switch to palliative medicine. In 2013–2014 I did a formal fellowship, and I am now a full-time palliative medicine provider.
Going into the fellowship, I expected to learn about pain and symptom management as well as communication skills. But I didn’t realize just how much I didn’t know about effective communication and how to frame an issue to promote understanding. Early in my fellowship year an awkward patient interaction taught me just how much I had to learn.
learning the painful truth.
Mr. P, a 56-year-old man with end-stage pancreatic cancer, was not doing well. Despite ongoing chemotherapy, his disease was progressing. His family brought him to the emergency room because his appetite was poor and he was becoming very weak. Based on his declining functional status (prognostication will be discussed in a future post), he likely had weeks to perhaps a few months to live.
I knew that.
However, Mr. P and his family did not.
Although they all understood he was going to eventually die from the cancer, they hoped that by increasing his nutritional intake (which in his case meant placing a feeding tube and starting tube feedings or alternatively starting IV nutrition) he would improve. In trying to discern his thoughts about the use of these artificial means for nutrition, I incredulously heard myself asking him, “if you are unable to take in enough nutrition by mouth- would you want a feeding tube?”. His wife’s response, ‘well if he doesn’t do that, then he’ll starve to death!”, confirmed that I had hopelessly botched this discussion. As the words were coming out of my mouth, I knew I had framed the question incorrectly, but I couldn’t think of another way to phrase the question. And I thought I knew how to effectively talk with patients?!?!? Obviously, I had much to learn. I am forever grateful to the hospice liaison nurse who thankfully interjected with a more effective frame for the issue, in part by emphasizing that it was the cancer that was causing Mr. P’s decline, not his lack of oral intake. The hospice nurse also gently explained that Mr. P was nearing the end of his life.
With this new understanding of his prognosis, Mr. P and his family were better able to grasp the full situation and make decisions aligned with his wishes. As we steered the conversation toward what Mr. P wanted, we could explain why tube feedings would not be beneficial, and he and his family concurred. Mr. P expressed a strong desire to spend his remaining time at home, surrounded by his family; he did not want to die in the hospital. Although struggling with this new reality, his family supported his decision. Based on Mr. P’s wishes, we were able to expedite admission to home hospice services. He died a few weeks later, at home with his family by his side, just has he had wanted.
So, this dog (me) had new tricks she desperately needed to learn.
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Physicians would help patients (and as importantly) their families on how dependence on medical technology at the end of life frustrates what likely everyone wants — a peaceful end, at home, not hooked up to tubes, surrounded by people they love. There is such a fear of death in our culture that it is often forgotten that it is actually part of life, and should be honored as such. Thank heavens for doctors like you who can support this idea.
We are always students. Love it!!!!