Over the last few months, I have taken care of many patients with injuries like the intraparenchymal hemorrhage above. I have found having conversations with the family and friends of these patients to be difficult to get through. Part of me believes this is because I don't really have the experience or expertise to answer their questions. The rest of me has decided that experience doesn't really change the fact that this sort of conversation is never easy.
In medical school, we practice breaking bad news to patients and families. I remember a particularly comical "practice session" in which my charge was to tell a high school soccer player that he would never play sports again because he tore his ACL. First off, pretty much everyone knows that an ACL injury is no longer a career ending injury. Second, sitting across from your friend, who's task is to play said injured soccer player doesn't really make for an accurate representation of what the experience of breaking bad news is supposed to be like.
Now, let's talk about the real life scenario, when you are the "neurosurgery resident" on call and the poor patient with an injury similar to the one above rolls into your ED. Literally, you are the only "neurosurgeon" in the hospital, and Grandpa's family has a million and ten questions. Grandpa is intubated and requiring medications to control his blood pressure. His neuro exam is nada, even with sedation off, and the ED doc says that the family would like to talk to the "neurosurgeon" before they make a decision on code status.
Nothing can prepare you for this experience when you are the person breaking the bad news, not even watching other physicians. To me, the most difficult part is the emotion involved. Getting past the obvious elephant in the room can be very hard. I'm not great at keeping my emotions out of the mix yet, and I'm not really even sure how much emotion is appropriate.
Oh, and then there's that little fact that facts aren't always the most important part of the discussion. Painting the big picture for this devastated family is not easy to do. I've noticed that the family doesn't always want to focus on the big picture, because I think it's too much to take in. It's easier to focus on the little things like vital signs and CT scans and getting the family past that can be a difficult task. At least getting the WHOLE family past that can be a difficult task.
I believe that the most important thing a physician can do in these circumstances is put the facts on the table. Explain what we know to the family and explain the uncertainty that comes along with these devastating injuries. Once everything is explained, we have to put the ball in the family's court and continue to do our jobs. It is important to revisit the family as the situation changes and they develop a better understanding of their loved one's condition and expected outcome. I also find bringing other specialists (like palliative medicine) to the table can help give the family a complete understanding of the situation at hand.
Some people might ask why I care. In five months, I'll be off to the happy land of Orthopaedic
Surgery. Although we don't necessarily deal with life and death every day in Orthopaedics, sitting a person down to explain that the best treatment for their injury would be an amputation is a difficult thing for patients to hear.
Although I said at the beginning of the post that experience isn't the primary determinant of how well a physician can handle these conversations, I do believe that it helps. The rest is people skills and being able to relate to our patients in a way that allows them to hear what we are saying and understand their options. Easier said than done...
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