Tuesday, 22 March 2011

Finding The Words

Those of you who've been reading the blog recently will remember my post about the young patient with cancer, and how concerned I was that no-one had told him anything.

As far as I was aware, from the notes and from what the consultant said, he'd been told his diagnosis last week. He seemed a bit more upset and agitated, but was in a lot more pain. I thought, considering everything, he was taking this bad news pretty well...

Then today I was involved in a conversation with the palliative care team, his nurse on the ward, the FY1 and I. Turns out he'd only been partially told.

I felt sick.

He'd been told that there was shadowing in his imaging, and that this was being further investigated. So really he had no idea. The doctor never explicitly used the word "cancer". The consultant was adamant that the patient knew what he implied. The rest of us weren't so sure.

It was left down to the palliative care team to go over to him and break the news properly, making sure he understood everything.

I've always thought it's important to say things as they are. Words like cancer and death are scary, but it's only fair that the patient knows what's happening. Or at least that's my opinion.

I know that when my Mum was dying in hospital it was a long time before we were told she had cancer and was dying. In fact it was only a couple of weeks before she died. I have no doubt that the team caring for her were aware long before us. Probably like my team they were waiting for histology and a proper management plan. Surely though, for someone with obvious mets, it's important to at least tell them that they have cancer.

I can't help but think that if we had a bit more knowledge about my Mum having cancer that she might have had the chance to die in a hospice, which is a lot nicer than a hospital. I also think it would have been a lot kinder on my Dad and I if we'd been told more and prepared a little more for things.

I just wish I was a bit more influential in the team so that I could help this family a little with what is clearly going to be a difficult time.

I don't think histology or the finer points of management matter that much to patients or relatives. What matters is knowing a realistic prognosis and the major options for the future. Home, hospital or hospice care? Saying goodbye to loved ones. Getting affairs in order. Sorting out finances and wills.

I'd like to know what other people think, or situations other people have been in? What would you do if you were the consultant?!

Lily xXx


Jenn said...

I agree, wholeheartedly. News like that should not be a shock to patients, a lot of the time that is what they will be worrying about and being told, if that is what they want - some patients will not want to know anything and that is their decision. Healthcare staff need to respect patients and be honest. They need all the time they can to think, process and plan. And cope.

Anonymous said...

Is your consultant a bit cocky or a nice guy? I once had a patient who had a weird Xray and several consultants were unsure whether it was TB or lung mets. So they decided to do the staining which took a while, and didn't want to tell him until the results were back. By the time they were pretty sure it was the cancer, he was confused and deteriorating and didn't understand. Then he died suddenly the next night.

It's slightly harder on the patient when the doctor has a thick accent but thinks people can understand him anyway. If the patient is still alert and oriented it's ok but not when their GCS is dropping, also I wonder why the regs never challenge the consultants (or SHOs challenge the regs) when they think they didn't actually break the bad news well, but complain to us instead!!

Anyway you know how you will act when you become a consultant. You can probably tell which of your colleagues in your year are going to be nice and who is going to not really care about patients. The problem is the second type find it easier to get through the interview when they are 17 years old.

Renal said...

I find it very difficult to break bad news without knowing myself what that news is.

We can all tell someone that they're dying, but it's fucking awful trying to answer their questions about when and how and why when we have barely answered those questions ourselves. Similarly, telling someone that they are going to die of cancer is difficult, reversing that decision when the histology suggests that chemo is a good bet can be just as awkward and challenging.

Anonymous, when I interviewed potential medical students, aged between 17 and 37(ish), we did get a sense of who might go on to care about patients. But in five or six years of UG education and ten, twelve or more years of on-the-job training, people and their attitudes can and do change. What's more, the attitude that people have when they whinge and gob off in the mess or the staff rooom or on the internet is often not the attitude they display to the patients.