Talk is cheap, or so they say, but not when decisions regarding life or death are concerned. Those decisions are played out in a variety of settings but especially in the intensive care unit (ICU) of any hospital. In this blog I’ll not consider the economic cost which, while significant, pales in comparison to the psychological cost of these discussions, both to families and physicians, that can accompany weighty decisions affecting critically ill patients. There are, however, a variety of reasons influencing how physicians subconsciously or consciously broach, or not, these serious discussions with a patient and/or family.
Allow me to begin by framing the topic accordingly. I recently gave a talk about medical issues to a small group of individuals. As part of the discussion I recalled three cases in which I was involved as examples of what challenges can be faced by both physician and family. These cases included an intubated patient with the potential for recovery but the family wanted her removed from the ventilator, a 92 year old man with multiple medical problems, all of which were gradually getting worse, necessitating transfer to the ICU as he and family wanted “everything done”, and a 28 year old woman with “treatment failure” melanoma metastatic to lung to the point that tumor burden was leading to increasing respiratory distress. The first case (detailed in a previous blog, Decisions) played out over a few days but the last two over a few hours as I had just met the patient and family. In all three cases I gave an overview of the issues as I knew them with the patient and/or family, listed possible options for going forward, and then made my recommendations. Time, relative to the immediacy of the situation, was given to the family to discuss among themselves and, eventually, with me. Decisions were made for what was thought to be in the best interests of the patient; in the first case the patient was not extubated early and eventually recovered, the 92 year old man did not mean by “everything done” to include mechanical ventilation or cardiopulmonary resuscitation, and the 28 year old was made comfortable and allowed to die in peace as further aggressive intervention would not have altered her outcome. Toward the end of our group discussion one of the participants, a priest, commented that he had been involved in any number of cases of critically ill patients where the physicians spent so little time talking to patient and/or family, contrasting my taking the time for discussion with other physicians who didn’t. He asked for my perspective as to why such a variation in physicians’ willingness to engage in such discussions.
The first thing to keep in mind is that physicians have varying degrees of comfort with these types of discussions. As medical students and residents we received no formal education on how to discuss issues such as these with patients. While there has been an ever increasing body of literature through the years about “how to” and, perhaps, a course here or there for an attending physician, most of us developed our style of approach and substance of discussion by watching others, usually one or several attending physicians or fellow residents. As you can imagine our styles became eclectic, picking what we perceived to be the best approaches and adapting them to our way of dealing with certain situations. For many of us it was on the job training and would, if we were fortunate, have a more seasoned physician with us who, under their watchful eye, would allow us to broach the subject while willing to intervene to assure the discussion did not get out of hand or off on a tangent. These mentors would often give mini-critiques afterward to help our communication style. Unfortunately, though, I think there were/are some trainees who never worked on their style either because of an inability (psychological?) to do so or their mentors were lacking in their own way (e.g. an attending physician who rarely, if ever, would discuss end of life matters). And, as one can imagine, without effective mentoring, the challenge of dealing with these kinds of discussions could become even more daunting and stressful.
Moving on, I suspect the pressure of time, real or imagined, plays the largest role in this variable engagement . When I was a resident I was a proponent of an “open” ICU policy regarding a constant family presence at the bedside in contradistinction to a “closed” time with limited visiting hours where nurses and/or physicians could complete tasks or rounds without have to interact with family at that moment. I had difficulty understanding why so many physicians were against an open policy until I spoke with a well respected surgeon who, after a back and forth regarding the merits or non-merits of such a policy, simply said, “Wait until you go into practice.” Several years later, now as a private practicer, I finally came to understand what he meant. As a resident I was in one place all day and had the luxury of speaking with family virtually at any time and, generally speaking, there were no time constraints as to the length of the discussion. Now, as a physician in private practice who, on a daily basis, had to split duties between hospital and office, felt the time pressure of getting rounds done and to the office on time vs. speaking with a family (or several) which could (and often did) delay the completion of rounds or lead to being late to the office. In time you learned to adjust as best you could–short meetings, placating irritated office patients because you were late, or returning to the hospital at the end of the day to either finish rounds and/or talk to families. Over the course of two of my practices (Pa. and Indiana) I also felt the time burden that “travel” (hospital{s} to office and vice versa) puts on a physician. There were also periodic challenges of trying to coordinate meeting times as families would not necessarily be available to meet when I was at the hospital. For those thinking, “Why just not pick up the phone?” remember, cell phones haven’t been around forever and time is lost when trying to find a phone number or calls aren’t answered or, when answered, the wrong party is responding. Voicemail is not an option for a variety of reasons. In my third practice (NC) I did shift work, scheduled in one particular area (ICU or ward) for a week at a time, and did not have to travel. What a luxury! In addition, when in the ICU, the residents would do a portion of the work thereby freeing up additional time for the attending to have one or several discussions with family every day (our ICU had an “open” policy). It also helped when families were available only certain times of the day.
While the time element is likely the most common reason for non-existent, limited, or truncated family discussions, there are others. We physicians are, in general, an optimistic lot, certain that with our skills and knowledge our patients will get better. Although, with that said, our optimism is not infrequently tempered by reality. There are some physicians, however, who retain an eternal optimism to the point where reality is denied. Nothing is more demoralizing than receiving in transfer to the ICU a critically ill patient who, already dealing with underlying chronic progressive medical illnesses, has experienced a new complication or illness requiring immediate intervention, while the attending physician of record lays out a glowing scenario to the family of, “They’re (ICU personnel) top notch and will get your loved one better in no time at all.” To all other health care providers involved, however, it is evident that the patient’s likelihood of survival is extremely poor. Now the challenge is to begin the difficult task of getting to know the overly optimistic and hopeful family, gradually and delicately introduce them the likelihood that there loved one is not going to get better, and not paint the attending physician of record as Pollyannish. This approach can take days and, obviously, discussion time of which the ICU physician may not have an abundance depending on circumstances or other obligations.
Another consideration regarding the extent of discussions with family or patient has to do with “the path of least resistance.” I have observed and talked to any number of critical care physicians who will spend more time trying to talk a patient or family out of a specific care plan rather than acquiescing to a care plan already proposed by other physicians. For example, the path of least resistance for the above referenced 92 year old man and the 28 year old woman would have been to proceed with decisions already made (aggressive resuscitation, mechanical ventilator) rather than to take that extra time to explain why those decisions would have little to no benefit to either patient.
As you might imagine it is easier to discuss difficult issues and arrive at certain decisions when the physician knows the patient and, at least tangentially, the family, and the longer the relationship the easier (relatively speaking) decisions can be made. Why is this? Trust. Trust that the physician has the patient’s best interests at heart and recommendations are made are done with these in mind. In my first two practices I would follow a patient for days, sometimes weeks and, rarely, months. I knew their history and learned the nuances of their care. I’d meet with family, even if briefly, and they came to know me and I, them. In my last practice generating trust became more challenging as my time on a particular service was limited to no more that 7 days. Getting “up to speed” with many issues regarding a particular patient usually took 1-2 days and sometimes almost the entire week. While family discussions were held daily it became easier to have those discussions and more time allotted as the trajectory of the patient’s progress (or lack thereof) became a little easier to discern. The most stressful times are when attempts at succeeding in generating that trust occur over a very brief period of time (e.g. the 92 y/o man and 28 y/o woman mentioned above).
Lastly, there are a few of us out there who just don’t like to discuss the situation especially when the outcome is highly likely to be poor. Why? Perhaps it is because of, in a way, admitting failure. Some physicians feel their responsibility is to assess the patient, write the orders and daily note but leave informing the patient’s family to someone else, either nurses and/or other physicians involved in the patient’s care. I remember in my first practice on an especially busy on call weekend getting a “stat” consult on a patient who, hospitalized several days earlier already critically ill, had now suffered respiratory failure and was just placed on a ventilator. After reviewing the chart, examining the patient, and speaking to the bedside nurses, I knew things weren’t going to end well for the patient in light of his ever worsening multiple organ failure. Being pressed for time, as I had two other hospitals to go to and many other patients to see, I’d planned to forego a family discussion that day. However, as I was leaving, one of the ICU nurses pulled me aside and said, “The family is waiting to speak with you.” Tag, I’m it. I stopped by an ICU meeting room full of people and, as it turned out, all related to the critically ill patient that I had just seen. Putting aside the recommended protocol for opening up discussions such as this, I introduced myself, paused, and then bluntly stated, “He is going to die.” Dead silence. Someone then rose, looked at me while making a sweeping gesture with his hand toward those assembled, and said, “Thank you. You are the first one who had the balls to tell us what we already knew.”
So there you have it. Why don’t some docs take the time to discuss important life and death issues? Time pressure assuredly but also factors related to unrealistic optimism, trust, just not wanting to talk and, finally, not wanting to acknowledge failure that a patient under their care was not going to get better. There may be more–what do you think?
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