When you have to say, “There is nothing more we can do”, there’s a better way to do it.

Unfortunately, there comes a time in a patient’s life where you have to say to the patient or their family, “I’m sorry, there’s nothing more we can do.” This is the wrong thing to say and let me explain why. I know what you’re trying to say is, “there is nothing more we can do to cure your disease” but what the patient or loved one hears is, “I’m giving up and walking out this door and never coming back.” I know that’s irrational and that’s not what you meant to say but unfortunately these words sound like abandonment to the patient or family.

I believe it’s important to tell the truth about prognosis (if the patient wants to hear it), even if you can’t give them an exact time give them an estimate. You can say days to weeks, weeks to months, months to years. People deserve the opportunity and time to clean up their lives. So, when you have to say that there really is nothing more you can do, you may be missing a really important piece to this conversation. Here is how to solve this. Go ahead and tell them that there’s nothing more you can do to cure the disease, and then continue on and say, “But there’s lots more I can do. I can do plenty to keep your loved one comfortable, out of pain, minimize their suffering, refer them to hospice, get your religious leader in here to pray and help provide a peaceful and dignified death.” Helping someone to have a pain-free and dignified death is substantial. I don’t know if you realize this but palliative care specialists have the highest satisfaction rate of all medical specialties. And why is this? It’s because this is profound and meaningful work. You really matter to the patient and the family on those last days of life. It is wonderful if you can say to the patient that you’re going to walk on this journey with them no matter where it takes you. Then they won’t feel abandoned and alone. You will still be the healer, but now the focus of your healing is to heal suffering, not the disease.

The other reason this technique works is because whenever you have to say no to a patient, it is always important to offer them something else in exchange. I don’t know if you’ve had this experience with young children when trying to take a breakable item out of their hands. A smart parent grabs their favorite toy and exchanges it with them or distracts them toward something else. The same thing can happen in medicine. If you have to say no to a patient then offer something that you can say yes to. Even if all it is good pain management or the hope for a peaceful death.

Have a kind and respectful day.

Don’t Tell Grandmother She Has Cancer

 

Dear Viki,

The other day, I had a family tell me to not tell their grandmother that she had cancer and was going to die soon. I am not sure what to do. I want to be culturally respectful but I also have to make sure that I am doing right by the patient. It is her life, not the families. What should I do?

Great question. If it was 40 years ago, a doctor could keep information from a patient. Now the rules are different. Here is what you need to do to respect the patient and the culture.

1. Speak directly to the grandmother, hopefully without her family in the room. Ask her, “Do you want the results from the tests we are doing or should I be talking to somebody else? Do you want to make your own decisions or would you prefer that someone else make those decisions for you?”

2. If she says, “Yes, I want to know the results and make my own decisions”, then you will know what to do. Tell her the information. You may also want to check with her if she would prefer to have these conversations in private or with her family present. Sometimes it is just as important to the patient to protect their loved ones as well. Respect the patient’s wishes while you show respect for this family’s culture.

If she says, “No, I would rather focus on getting better and let someone else deal with all of the decisions”, you also know what to do. You now must ask her, “Who should I talk to?” Once she tells you who is in charge, and it might be a 2-3 people, then talk to them. This is called a waiver of informed consent. Patients can act autonomously and waive their right to information. You may want to have her to fill out an advance directive or living will ahead of time and check the box on the form that says, “Starting now, I want _____ to make my decisions for me even though I still have capacity.” If she changes her mind later on, then you can follow her new instructions and begin having her give her own informed consent.

Have a kind and respectful day.