“I love you mom, I’ll miss you when I’m at camp!” Scrawled on the poster hanging in her room.
A wife and mother, obviously dearly loved and only 45. The previous night I promised to give the cytology results as soon as we knew. “At least for now no news is good news, and I have one less night to worry,” she revealed. Her perspective was completely the opposite of most patients or my own.
Mid morning I heard from my attending, the cytology was positive for malignancy. The team - myself (the intern), my senior, the attending and the medical students - apprehensively crossed the threshold of her room. Privately the team was devastated. Graciously my senior agreed to run the meeting. Revealing a devastating diagnosis is anxiety inducing for anyone. It’s still hard for me to contain my emotion as a provider with these conversations, I am getting better - and experience is helping. Her eyes were red with fresh tears and heartbreak. She knew.
By chance, or not, our grand rounds earlier that morning was on conversations in serious illness. It seems like in medicine as soon as I learn something, or a grand rounds/noon conference etc is presented, I can apply it. We discussed the tool that I’ve included in this post which was published in this article Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices in JAMA 2014.
As I listened to my senior gently walk through these questions, my heart broke for her. She was strong and wanted to fight with another round of chemo - we discussed her goals, wishes and tradeoffs.
I’ve now used this tool several times and to be honest each time I have this conversation, the responses intrigue me and almost surprise me at times. Most of what I would’ve assumed, would have been wrong. It’s humbling and reassuring that the patients have made their decisions prior to ever needing them.
I recently finished Being Mortal by Atul Gawande where he discussed Dr. Susan Block using this tool with her father. (I highly suggest this book to everyone in medicine or not.) She was surprised, and relieved that she had this conversation with her father. It made her decisions easier, because they weren’t her decisions they were her fathers.
As we are starting a new year,I encourage you to try this tool as a conversation guide. The guide was meant to use with clinic patients or during post hospital visits, but some of the language is helpful for family meetings, especially the opening. It’s certainly helped me, I used to loathe these conversations. But as the year moved on and I became more comfortable with end of life, these conversations became more tolerable and important to me.
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