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Giving bad news
REFLECTIONS
Giving Bad News Amanda A. Mun ˜oz, MS IV Harvard Medical School, Boston, Massachusetts There were 5 patients waiting for us in the emergency department. My giraffe-sized resident raced through the halls at an Olympic walking pace; I tried desperately to keep up while being careful not to twist my ankle on my clogs and fall down. The woman we saw was groaning on the stretcher, and her husband was apprehensive in the corner. She was intensely nauseated. We interviewed her briefly and then mashed on her belly. I started to think about what would be at the top of my list of differential diagnoses. Before I got to the third item on my list, my resident dashed out of the room. I pushed the curtain aside in an attempt to follow him, only to have him race by me in the other direction holding a nasogastric tube. “We’re going to put this down into your stomach so that you feel better while we’re waiting for that CT,” he said. “Does that sound ok?” He was already dipping the tube in lubricant. She had trouble sitting up because she was so nauseated. “I’m going to pass out. I’m going to pass out,” she chanted. “I’m going to lose my water. I’m going to lose my water.” She lost control of her urine all over the gurney. “I can’t sit up, I can’t sit up.” We yanked her up by her elbows, forced her chin to her chest, and I put the tube in her nose and asked her to swallow. She groaned but we got it down. We jammed it into the wall suction and ran out of the room. Her husband stroked her foot as she lay silent, her eyes closed. “Rena, sit up,” he said, his voice pleading. “It’s ok.” We ran to the intensive care unit to check on our other patients. We hustled back to the emergency department, trying to make stealth consult visits so as to avoid the questions from the emergency department doctors that, I was told, would inevitably develop into more consults. We sprinted to radiology. Her scan showed a small bowel obstruction, but also we found a large mass on her right kidney, which the radiologist deemed “almost surely a renal cell.” We trucked back into the room. Correspondence: Inquiries to Amanda A. Mun˜oz, MS IV, Cannon Society, Tosteson Medical Education Center, 260 Longwood Avenue, Boston, MA 02115; e-mail: [email protected]
“You’re going to have to stay with us tonight,” my resident said abruptly. “There’s something blocking up your intestines and you have a big old tumor on your kidney and we have to figure it all out.” “I have a tumor? Is it cancer, doctor?” “We don’t know yet. We’ll have to talk about it later, ok?” “Oh, ok.” She closed her eyes again. Again, we ran out of the room, flipping the curtain closed behind us. I turned my head to make sure it was closed while trying not to lose too much ground behind my resident. Her husband stood at the foot of the stretcher, gently stroking Rena’s foot while she rocked back and forth, eyes closed, groaning, with our tube in place and her new diagnosis. As we ran down the hall toward the operating room, I felt terrible. There was so much that had gone wrong about the situation. Five months of clerkships had shown me that the ideal patient– doctor relationship taught in classrooms and acted out on videotapes crumbles under the demands of ward work. I had already begun to prioritize my efficiency, interests, and performance over the patient’s feelings and questions. Even so, I felt ashamed that we had neither listened, nor made her feel comfortable, nor prepared her in the slightest for a diagnosis that we knew she would not understand. And yet I felt hesitant to blame my resident. He was in an impossible situation; every call night I trailed him and witnessed the incredible volumes of patients and problems about which he would be required to speak confidently the next morning. Additionally, I saw what was said to him when he was not able to cover all of his bases. Who could blame him for not being compassionate with too much work and too little time? Neither I nor anyone on my team ever saw Rena and her husband again. A couple of days later I wondered what had happened to her. I thought about looking up her results on the computer, or walking by her room after checking to see if she was still in house. I decided that I was too busy; there too many other things to get done before rounds started again. I, too, had put efficiency before interest and was already following in my resident’s footsteps.
CURRENT SURGERY • © 2005 by the Association of Program Directors in Surgery Published by Elsevier Inc.
0149-7944/05/$30.00 doi:10.1016/j.cursur.2004.05.004
71
Giving Bad News Amanda A. Mun ˜oz, MS IV Harvard Medical School, Boston, Massachusetts There were 5 patients waiting for us in the emergency department. My giraffe-sized resident raced through the halls at an Olympic walking pace; I tried desperately to keep up while being careful not to twist my ankle on my clogs and fall down. The woman we saw was groaning on the stretcher, and her husband was apprehensive in the corner. She was intensely nauseated. We interviewed her briefly and then mashed on her belly. I started to think about what would be at the top of my list of differential diagnoses. Before I got to the third item on my list, my resident dashed out of the room. I pushed the curtain aside in an attempt to follow him, only to have him race by me in the other direction holding a nasogastric tube. “We’re going to put this down into your stomach so that you feel better while we’re waiting for that CT,” he said. “Does that sound ok?” He was already dipping the tube in lubricant. She had trouble sitting up because she was so nauseated. “I’m going to pass out. I’m going to pass out,” she chanted. “I’m going to lose my water. I’m going to lose my water.” She lost control of her urine all over the gurney. “I can’t sit up, I can’t sit up.” We yanked her up by her elbows, forced her chin to her chest, and I put the tube in her nose and asked her to swallow. She groaned but we got it down. We jammed it into the wall suction and ran out of the room. Her husband stroked her foot as she lay silent, her eyes closed. “Rena, sit up,” he said, his voice pleading. “It’s ok.” We ran to the intensive care unit to check on our other patients. We hustled back to the emergency department, trying to make stealth consult visits so as to avoid the questions from the emergency department doctors that, I was told, would inevitably develop into more consults. We sprinted to radiology. Her scan showed a small bowel obstruction, but also we found a large mass on her right kidney, which the radiologist deemed “almost surely a renal cell.” We trucked back into the room. Correspondence: Inquiries to Amanda A. Mun˜oz, MS IV, Cannon Society, Tosteson Medical Education Center, 260 Longwood Avenue, Boston, MA 02115; e-mail: [email protected]
“You’re going to have to stay with us tonight,” my resident said abruptly. “There’s something blocking up your intestines and you have a big old tumor on your kidney and we have to figure it all out.” “I have a tumor? Is it cancer, doctor?” “We don’t know yet. We’ll have to talk about it later, ok?” “Oh, ok.” She closed her eyes again. Again, we ran out of the room, flipping the curtain closed behind us. I turned my head to make sure it was closed while trying not to lose too much ground behind my resident. Her husband stood at the foot of the stretcher, gently stroking Rena’s foot while she rocked back and forth, eyes closed, groaning, with our tube in place and her new diagnosis. As we ran down the hall toward the operating room, I felt terrible. There was so much that had gone wrong about the situation. Five months of clerkships had shown me that the ideal patient– doctor relationship taught in classrooms and acted out on videotapes crumbles under the demands of ward work. I had already begun to prioritize my efficiency, interests, and performance over the patient’s feelings and questions. Even so, I felt ashamed that we had neither listened, nor made her feel comfortable, nor prepared her in the slightest for a diagnosis that we knew she would not understand. And yet I felt hesitant to blame my resident. He was in an impossible situation; every call night I trailed him and witnessed the incredible volumes of patients and problems about which he would be required to speak confidently the next morning. Additionally, I saw what was said to him when he was not able to cover all of his bases. Who could blame him for not being compassionate with too much work and too little time? Neither I nor anyone on my team ever saw Rena and her husband again. A couple of days later I wondered what had happened to her. I thought about looking up her results on the computer, or walking by her room after checking to see if she was still in house. I decided that I was too busy; there too many other things to get done before rounds started again. I, too, had put efficiency before interest and was already following in my resident’s footsteps.
CURRENT SURGERY • © 2005 by the Association of Program Directors in Surgery Published by Elsevier Inc.
0149-7944/05/$30.00 doi:10.1016/j.cursur.2004.05.004
71