Communicating with patients: A dying art

A small news item in The Jerusalem Post last month created a big stir during my lunchtime discussion with colleagues. The newspaper’s health editor, Judy Siegel, reported that a physician had been attacked at the Intensive Care Unit of the Western Galilee Hospital. For many readers, the news was further proof of an urgent need to pressure the Health Ministry to add beds in Israeli hospitals. Dr. Nimrod Rahamimov, head of the Doctor’s Committee at WGH, pointed out that “overcrowding contributes much to the atmosphere of anger” and cited that throughout the year – for example, even when it is not influenza season – occupancy has never dipped below 150 percent in the ICU. Rahamimov went on to suggest that “only if uniformed policemen are present will attackers understand that the hospital is not a place for violence.”

Embedded in the article was a subtlety that was easy to overlook in the midst of Rahamimov’s rant about inadequate hospital resources. As it turns out, family members became aggressive – “holding the physician tightly and throwing her against the wall” – moments after the doctor informed relatives that the patient had a terminal condition. Not all story details have been revealed, but rather than hold our breath for the Israeli government to gift us with additional ICU beds, and before we turn our hospitals into mini police states to maintain order, we might contemplate remedying the problem from within.

Would anyone be shocked to learn that the emotional flare-up coincided with the stresses associated with breaking bad news and in turn absorbing this information? I am not attempting to assign blame or explain away the particulars of what was surely a tense encounter. Yet in some ways, I am surprised that we do not read about more volatile incidents in hospitals.

As an oncologist, I reflect often on end-of-life scenarios. Truth be told, anyone who chooses a career in medicine can’t avoid death and at some point must either engage in intense denial or confront mortality – one’s own as well as that of one’s patient. Most physicians deal with death or its specter on a day-to- day basis. Are medical professionals, and members of society at large, equipped to handle the natural phenomenon of death?

Surely no one craves talking about unpleasant subjects. Who wants to be put in the unenviable position of communicating bad news? Wouldn’t it be preferable to seek a career like that of “Ariella” – the Israeli lottery spokeswoman whose sole task is calling winning ticket-holders to inform them of the extent of their haul?

In 1910, medical education in North America experienced its first major reform in response to publication of the Flexner Report. Many regard that document as the birth of modern medical education because it tightened up a lax system and mandated that teaching be rigorously oriented around the biomedical sciences. During the past decade, however, both the Association of American Medical Colleges and the American Board of Internal Medicine concluded that an over-correction had occurred, driving many physicians to become more distant and less supportive. Recently, new curricula have been approved in US and Canadian medical schools that underscore empathy training with a heavy dose of seminars designed to build communication skills when contending with end of life issues. This is an experiment that must not fail!

The subtext of discussing death with patients and families requires that doctors overcome their own sense of loss or failure. For physicians, it implies a willingness to be vulnerable. But what could be more human? This conversation between doctor and patient,

“The Conversation,” is a sacred encounter. However, the physician and the patient walk into the encounter with very different frames of reference. For that reason, we must not take for granted that the two parties will connect. The patient is looking for good news and, sometimes, magically thinks that if the physician will like him more then there is an increased probability that good news will be provided. But when there is bad news, the worst possible news, there can be an unleashing of raw emotions and even rage. It all may seem outrageous as it unfolds but can we create a safe place for these charged feelings? Do healthcare professionals have the tools necessary to navigate the crisis?

Simultaneously, another movie is running. The physician enters the room and also wants the best, but like any human being can be easily distracted. Perhaps the doctor received a text message, just moments prior to sitting down with the patient, advising that his teenage daughter was involved in a motor vehicle accident. No one was injured, and only the car’s fender has been bent in our hypothetical case. But the physician, as dad, still worries about his child’s well-being, the cost of repairs and the impact on his insurance premiums. By definition, barriers have now been erected between doctor and patient. It takes training and experience to be able to compartmentalize these issues and separate them out so that care is not compromised.

Finally, the physician is ready to offer counsel. It’s truly hard to know what to say when someone is dying. Yet, physicians need not be afraid to address the realities of death. They can set the tone with both verbal and body language. Doctors can acquire a comfort level “to be present” with families and their dying loved one. They can express sorrow without fear that they will be misconstrued as weak or worrying about legal consequences. That is true whether death is foreseen, unexpected or even associated with complications of hospitalization or medical intervention. In any of those circumstances, the physician will have opportunity to transcend technical medical duties and insert meaning; meaning that can color the moment and continue to ripple through the sensibilities of survivors.

Ariella, God bless her and may she call my cellphone soon, will continue to deliver euphoria on a rare-event basis. On the other hand, the dying process – the most certain of experiences – can be uplifted, if we do not run or hide when life ends, but prepare ourselves for the privilege of being there.

The author is professor of oncology at Tel Aviv University School of Medicine, chairman of the Institute of Radiotherapy at Tel Aviv Medical Center and co-founder of Life’s Door- Tishkofet. He was awarded the National Citation for Volunteerism by President Shimon Peres.