The mere idea of working in an intensive care unit (ICU) gave goose bumps. I wasn’t sure whether or not I would be able to adapt to this new environment where patients are in need of critical care. I went to block headstrong and open minded. I did, however, feel crushed when I heard one of my patient’s tragic story.
I had an amazing experience working within the acute spinal cord injury ICU. However, I picked up something strange with regards to patient-physician communication. The majority of patients I worked with indicated that the doctors failed to inform them about their prognoses.
One of my patients, who was twenty years old and very active, became a paraplegic within the blink of an eye. One day, during a treatment session he asked me, “Can I please ask you something?” I replied with a smile and told him he’s welcome to. He posed a question that shocked me to my core. “Will I be able to walk again? Or do my sport again?” For a moment I paused and soon realized that the doctors didn’t tell him and that I’m most likely going to be the bearer of the bad news. I asked him if the doctors explained what happened to him. He looked at me with a blank, pale face and said no. I instructed him to ask them first. That day during ward rounds, he smiled at them and said he is doing well. And as expected, I had to break the news to him later that day.
Patients with spinal cord injuries (SCIs) suffer a traumatic and unexpected loss. These are considered one of the most devastating injuries an individual can experience. It accompanies big changes and consequences for the rest of the individual’s life(Nas, Yazmalar, & Ones, 2015). The prognosis of the patients is of utmost importance – not only for the sake of the patient, but also for the rehabilitation team. Thus, ensuring a realistic and patient-orientated treatment intervention (Kirshblum & Fichtenbaum, 2008).
Once the doctors conclude the patient’s prognosis, it is expected of them to explain it to the patient and family, however normally this is not the case. I realized that communicating this kind of information to the patient and their families can be a daunting task. In addition, this is likely to be a cause of distress in physicians.
During ward rounds, the patient indicated that he didn’t have any questions or complaints. During our treatment session my patient informed me that he was too scared to ask his doctors about his prognosis. The mere thought of me asking the doctors to do their job made me uncomfortable. I had to explain to him in laymen’s terms what happened to his spinal cord during his accident. I explained to him that the surgery he had was to stabilize the vertebrae that was injured – I emphasized that the surgery performed was not to “fix the problem”.
According to Kirshblum & Fichtenbaum, some physicians believe that discussing ‘bad news’ with the patient soon after the injury can be the result of anxiety and depression. I partly agree with this statement, however, I also think that informing the patient about their prognosis at an early stage can prevent them from setting unrealistic goals, resulting in disappointment. A recent study has shown that when patients are informed about their condition and are active in their rehabilitation, they are likely to have a better outcome (Sullivan, Menapace, & White, 2001).
From my experience of working in the ASCI ICU, 5/9 patients I worked with did not know what their actual prognosis was, therefore asked us as students whether their “legs will come right”. Until recently physicians experienced the greatest difficulties in asnwering this question accurately. Recent advances in clinical SCI research have led to the introduction of valuable tools for the prediction of functional outcomes after SCI(Middendorp, Goss, & Scheutz, 2011). Therefore, after concluding the prognosis with these tools physicians have no excuse why they are unable to inform their patients about their functional abilities.
The vast majority of patients want to be informed about their conditions. These patients also thought that physicians have an obligation to inform patients of their condition and they would want to be told if they have a life threatening illness (Sullivan, Menapace, & White, 2001). I have learned that patients will direct questions at students whether it falls within our scope of practice or not. This is due to the mere fact that they see doctors as individuals with the highest rank in the healthcare system. As a result, they engage in conversations with students much easier, due to us spending more time with them than physicians.
At first I felt uncomfortable and informed the patient that he has a right to ask the doctors any question with regards to his condition. Both the patient and physician has a role to play in this scenario. The patient must use each opportunity to direct questions at the physician to avoid misunderstandings. Physicians on the other hand need to treat patients with the necessary respect and dignity by including them in the discussion of their conditions with other physicians.
Honesty, empathy and clear communication are essential to delivering news to patients and their families – even if it is unpleasant. Communication between physician and patients is an integral part of the practice of medicine(Leng, 2015). If a similar situation were to arise, I would first address the patient’s physician as they are the first-line of practitioners in the case of SCIs. If the physician did not inform the patient, I would do it myself.
References
Kirshblum, S., & Fichtenbaum, J. (2008). J Spinal Cord Med. Breaking the news in spinal cord injury, 7-12.
Leng, S. (2015, April 22). MEDPAGETODAY’s. Retrieved from KevinMD.com: https://www.kevinmd.com/blog/2015/04/why-the-chasm-between-doctors-and-patients-its-all-about-money.html
Middendorp, J. v., Goss, B., & Scheutz, M. (2011). Diagnosis and Prognosis Traumatic Spinal Cord Injury . Global spine journal, 1-8.
Nas, K., Yazmalar, L., & Ones, K. (2015). World Journal of Orthopaedics . Rehabilitation of spinal cord injuries, 8-16.
Sullivan, R., Menapace, L., & White, R. (2001). Truth-telling and patient diagnoses. Journal of Medical ethics, 192-197.
3 thoughts on “The bearer of bad news”
Hi Tameron Lee
Thank you for sharing your writing piece. This can be a very uncomfortable situation and I feel you handled it well by advising the patient to ask his physician. I could very much relate to your situation as I myself have been placed in situations where patients did not know their diagnoses or their prognosis, so I could emphasize with you in this regards.
Content: I feel the content of your writing piece related well to the topic of ethics and professionalisms of the ethics module. You explained the scenario well and your actions and thought with regards to the scenario. You mentioned that you told the patient to ask his physician regarding the diagnoses, but also mention that you had to break the news to him later that day. Perhaps you could elaborate more on this – what led to you having to do this and how you dealt with the situation. Was it challenging and in what regards or how did the patient react. Did you talk the physician regarding this situation maybe? I think if you could maybe explain a bit more of this is would give the reader some more insight to your situation.
Argument: Your argument states the fact that you believe physicians should be the ones to break bad news to patients regarding their prognosis. Perhaps you could strengthen this argument and explain why you feel that allied health professionals (like physios) should not have to take on this responsibility? Perhaps you could also strengthen the argument about whether or not you believe patients should be told early on about their prognosis or later? I read that you argued for and understood both sides, but I was a bit unsure which one you believed to be right and which one you felt should be done. Out of this scenario, what have you learnt in terms of future situations like this, will you act the same or what could you do to prevent this from happening again (perhaps look at multi-disciplinary team with the physicians).
Spelling and grammar: There were a few minor spelling and grammar errors in your piece. I used hypothesis to add annotations to highlight them for you.
References: You have both in-text references as well as a reference list, but I think it would greatly benefit your piece if you could maybe add some more references of different sources if possible.
Overall I enjoyed your piece very much and I think it is a very relatable situation and topic.
I hope you find my comments helpful. Please feel free to let me know if anything was unclear.
All the best for your final piece.
Janine
Hello Tammy,
Thank you for allowing me to read your piece on bearer of bad news. I enjoyed reading your piece and gaining insight to what this topic means to you. Your writing piece reflects on the topic’s discus in the class. Therefore, I would rate your content as good. This is definitely not a situation any student would want to be in. You fully grabbed my attention when quoting the twenty-year-old, where the patient did not know about his prognosis in paragraph 3. Perhaps you can make it even more powerful by elaborating on how you felt in that moment and what emotions you were feeling when you had to explain his prognosis later that day. Maybe you could also give us more insight to why you had to explain the patients’ prognosis and not the doctors? Was the patient to afraid to ask them, or were they to busy to consult the patient? Later in the writing piece you mentioned that 5/9 patients you worked with did not know their prognosis. Perhaps you can add how this influences your treatment. How did you answer them when they asked whether their, “legs will come right”? If you add this in your piece it will link with the reference from Sullivan, Menapace, & White, 2001.
I like the argument you made surrounding this dilemma. You explained both sides well in paragraph 6. Perhaps you can make you argument stronger by adding more reasons to why/why not doctors inform their patients about their prognosis as soon as they concluded it. As you mentioned patients will direct these questions to students. As students we are still learning and therefore some of us will struggle to answer these questions. Students can often give misleading information. Therefore, maybe add that doctors should therefore consult patients about their prognosis or consult students on how to deal with the questions raised.
The reference list and in-text references are correct. You can always add more references as this will benefit your writing piece. Try adding references from recent years.
Few grammar errors that I have noticed:
First paragraph:
• Second sentence: Change I’ll to I would
Second paragraph:
• Last sentence: Add with after, “I worked…”
Third paragraph:
• First sentence: Add hyphen, “twenty-year-old”
Fourth paragraph:
• Fourth sentence: Change important to importance
• Last sentence: Add a comma after “Thus…”
Last paragraph:
• First sentence: Add a comma after “At first…”
• Second sentence: Change has to have. “Both the patient and physician have”
Overall, your writing piece touches on a real ethical dilemma where both the patient and physicians have a role to play. The paragraphs were well constructed and easy to read. I hoped my comments are going to help.
Good luck with your final
Megan
Hi Tammy
Thank you for this very interesting submission. This is a very complex ethical dilemma and many emotions are involved for the patient as well as for the health professionals working with the patient.
I liked that you explained why a doctor perhaps wont explain the patient’s prognosis too early in fear of creating more anxiety, but perhaps you could research at what stage is deemed appropriate… is there a guideline that doctors use?
Whilst this created an ethical dilemma for you, perhaps explain exactly what feelings you experienced at this time, and then again when you saw that the patient did not end up asking the doctor about his condition. I think you should also include what you would do in the future if this situation arises again, as you mentioned that a number of your patients didnt know their full prognosis.
I also think you could perhaps discuss whether it is not also part of a physiotherapists scope to explain to the patient regarding their prognosis… or is it assumed its only the doctors responsibility? Perhaps it should be a group discussion with a MDT so that all health professionals tell the patient the same thing, so as not to confuse the patient.
I noticed a few spelling mistakes, so just read through your piece after making your final changes. Eg. in your first sentence… add “me” after gave. end of paragraph 2, after worked… add “with in ICU”.
I hope these suggestions assist you in completing your writing piece. Good luck!
Halinka