Preparing Ourselves, Our Trainees, and Our Patients: A Commentary on Truthtelling

Abstract

In her article “Truthtelling,” it is abundantly clear that Dr Lindsay E. Rockwell experienced a great deal of frustration and sorrow, as well as pain, on confronting the imminent death of her patient, Jack, and the suffering of his loving father. She discusses the lack of communication with the patient and his family and its significant impact on his care near the end of life. Rockwell suggests the medical team betrayed both the father and the patient by not being truthful. Let’s take a closer look at the sources of this apparent betrayal. There are many ways and opportunities for communications to go astray, especially in such a tragic case of a young man in the prime of life. Oncologists spend many years mastering the many nuances of chemotherapy and the management of all associated toxicities, gaining confidence and comfort dealing with treatment protocols and adverse effects. Concurrently, they learn to explain difficult concepts, such as risks and benefits of treatment to patients, and how to frame these with the appropriate use of statistics regarding response and survival. Yet many oncologists are still not adequately trained in communicating prognoses or dire news. It is perhaps easier, and certainly more familiar, to describe the next regimen and its adverse effects than to address the big picture and negotiate goals of care. Discussing death and preferences for end-of-life care should ideally flow from conversations about life. Knowing what is important to our patients, what they treasure and think is worth fighting for, and how they wish to be remembered helps guide the dialogue when we run out of treatment options. Could it be that the patient’s father was correct when he said “No one told us Jack was dying”? If so, this is a betrayal by the caregivers and highlights the need for open and honest communication about prognosis and the consequences of not knowing. Lack of training, a desire to avoid painful discussions, an overly optimistic view of the effectiveness of current therapies, collusion between physicians and patients, as well as lack of time all contribute to a physician’s silence. But communication is a twoway street. Let’s focus on the recipient of the news, in this case, the patient’s father. Did he really not know? Was he afraid to ask? Was he unable to hear? Perhaps he simply could not bear to accept that modern medicine and technology could not save his son. Rockwell also expresses anger and frustration at the situation, accepting the father’s expression of grief as truth. But was she present for all conversations? Could it be that Rockwell is expressing her own grief as guilt for not speaking up when she saw the inevitable truth? Coming to terms with the limitations of current treatments and our collective failure to salvage and rescue every patient from death is both difficult and painful. It unleashes our own grief, which is often repressed. Let’s face it: we work in a culture that does not encourage the expression of emotion, and one regrettable consequence is that we often fail to provide a road map for personal coping for our trainees. Feelings of failure and sadness complicate the oncologist’s response to a patient’s demands for more treatment and may lead to unreasonable prolongation of futile therapies and the avoidance of an open discussion that death is near. This case illustrates the damage that can be caused by avoiding frank discussions about death with our patients and their families and not paying enough attention to the well-being of our trainees. We know that the time before death can be experienced as a period of growth and transcendence. With proper forewarning, a person facing an incurable illness has an opportunity to avoid toxicities from futile treatments, heal old wounds, craft a legacy of peace and love, and find solace in having completed meaningful tasks. This is borne out in practice and is the message repeated by those who are dedicated to caring for dying patients. We need to remember the wisdom of Dame Cicely Saunders, founder of the modern hospice movement, who taught that, given enough time and opportunity, most patients find their own sources of strengths and resiliency. Why is it that we are not more supportive of the enormous emotional toll this work takes on younger physicians and on our more seasoned colleagues as well? Those of us who work in teaching hospitals and those mentoring junior colleagues in practice need From the Mayo Clinic, Rochester, MN; and Massachusetts General Hospital, Boston, MA.