At our exciting and energizing annual meeting in Chicago, I had the honor and privilege of sharing my goals for SHM for the coming year: to promote palliative care and research in SHM and hospital medicine. Research will maintain SHM’s role as the leader in defining hospital medicine, and palliative care will keep us connected to our fundamental mission, which is to provide the highest-quality care to our patients. Over the next year I will share my vision for why I think these initiatives are key for SHM and our field and how SHM will promote them.
Recently, family of Mrs. T., a 62-year-old woman with metastatic pancreatic cancer, asked me not to tell Mrs. T that she was dying of her disease. Mrs. T had been admitted with severe pain and nausea. She could not eat and had been losing weight. Her pain had gotten suddenly worse. We treated her pain and nausea aggressively and achieved good control of both. Before I saw Mrs. T, her husband and 2 daughters took me aside and told me that although they realized that she was dying of her disease, they feared that she would lose hope if I told her how sick she was. “Let her think that she can get chemo in the future,” they implored. I asked why. “So she will think she can get better,” they answered. I asked Mrs. T.’s family what they thought she thought was going on. “She knows she is sick but believes the chemo can make her better,” they said.
This was not the first time I had encountered such a request, but it always makes me uncomfortable. What if they are right? Couldn’t I hurt her by giving her bad news she doesn’t want to hear? But if they were wrong, wouldn’t I be denying her the opportunity to say good-bye and bring closure? I took the middle road. I promised the family I wouldn’t say anything the patient didn’t ask me to tell her, but I would offer her the opportunity to ask. My first question to her was a typical open-ended one: “How are things going for you?” Mrs. T. said, “Well my daughter spent the night with me in my room last night.” I nodded. “I think she did it because she thought I might die over night,” she said. Perhaps as I suspected, she understood more than her family thought. She worried about her husband and how he would do without her. She wanted chemotherapy but realized that the best it could do was prolong her life a few months. When I asked her what she hoped for, she told me she has hope in God. I explained that I had spoken with her family and told them what I had told her. I said that they were concerned about her and were afraid that this knowledge would be too much for her. We talked some more, and then she asked me to have her husband come to her. There were things they needed to talk about. Next she spoke with her daughters. All were grateful for the opportunity to talk openly about their grief, sadness, and love for each other. Mrs. T. died 2 days later.
I share this story because it reaffirmed for me the crucial role that I play as a hospitalist in the care of people with serious and terminal illness and the importance of palliative care in providing the highest quality of care to these people. Caring for Mrs. T. raised many issues: effective treatment of pain and nausea, discussion of prognosis, respect for cultural differences, exploration of spiritual issues, and a request from the family to withhold the truth. I felt like I was trying to delicately balance respecting the family’s wish while honoring my responsibility to the patient to tell her the truth. In the end, a careful conversation allowed me to bridge the gap and get Mrs. T. and her family talking. My conversation with her husband several days after she died reaffirmed the importance of raising these issues with Mrs. T.