Timothy M. Pawlik, Shishir K. Maithel and Nipun B. Merchant (eds.)Gastrointestinal Surgery10.1007/978-1-4939-2223-9_45

45. Delivering Bad News: Conversations with My Surgeon

Murray F. Brennan¹

(1)

Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

Murray F. Brennan

Email: brennanm@mskcc.org

Keywords

CommunicationSurgeonsComplicationsPerioperative deathDifficult situationsDifficult families

Introduction

Almost all successful human interrelationships succeed because of shared and understood expectations whether between spouses, parents and children, employee and employer, business partners, or doctor and patient. If expectations are understood by both participants, then much of the rancor and future potential conflict can be avoided or ameliorated.

No better example of this is seen than between surgeon and patient prior to the performance of a major surgical procedure. Much of the difficulty and angst encountered in delivering “bad news” occurs because of the failure to anticipate a poor outcome because of either unrealistic expectations of the patient, his or her family, or the failure of the surgeon to convey the potential for less than a perfect outcome. No surgical procedure can ever be perfect and there are situations when unanticipated problems do occur. The ability to minimize the unanticipated is foremost in making delivery of bad news tolerable and less likely to engender anger.

Informed Consent

Informed consent is intended to convey just that, “informed” consent. It is your devoir. The importance is underappreciated by the surgeon who delegates consent to a junior member of the team. We need be cognizant that informed consent is often offered at a time when the patient is most vulnerable, and often obtained at a time when patient receptivity is at a minimum. Presentation of a diagnosis of cancer of the pancreas or the anticipation of a pancreatic cancer is accompanied by mind numbing shock and rarely delivered in a situation where calm and considered “informed consent” can be obtained. Legal requirements of informed consent are often vague, poorly understood, or interpreted by patient and surgeon alike [1]. When one anticipates that some form of complication minor or major occurs in up to 50 % of patients undergoing pancreaticoduodenectomy, one realizes how infrequently such potential events are described. Conversely, the willingness to emphasize complexity of any procedure and the potential of some complication occurring is essential to future rapport. This can be simplistically conveyed when talking about the duration of hospital stay. The mention of the anticipated postoperative stay, that is the statistical median, should always be tempered by “should a complication occur hospital stay will be prolonged.”

Hospital readmission is not uncommon and should not be feared but anticipated. With the current emphasis on early discharge, the patient should be informed of the likelihood of readmission. Currently 25 % of complications of major procedures occur post initial discharge, and the majority of those will require readmission [2].

The personal investment of the responsible surgeon’s time in obtaining his or her own informed consent is an excellent investment in the long-term surgeon–patient relationship. The inclusion of the family in this discussion is crucial. No greater potential for misunderstanding occurs than when conversations with the family either do not occur or occur in the absence of the patient, such that subsequent interpretation is seen differently by either side. A simple hand-drawn diagram outlining the planned procedure can often convey a sense of intimacy that is well appreciated.

Of additional importance for all major procedures is that all members of the team are “on the same side.” This is of most help, if one has a personal nurse or assistant who is familiar with your approach to procedures and can reinforce and explain, always being consistent. As a junior faculty member this may not be possible as variable support staff is available at the time of the initial visit. This means even greater importance of the participation of the primary surgeon. If you are unaware of the approach of your support staff to patients, your personal involvement must increase.

The simple offer of a willingness to discuss things further between the time of initial visit and consent and the planned procedure can do much to allay concern and defray the potential for misunderstanding. This offer sets the awareness that the surgeon and members of his team are available and willing to address concerns of the patient and family both pre- and postoperatively.

Empathetic informed consent should rarely, if ever, be obtained with either surgeon or patient standing. The simple effort of sitting beside or in front of the patient as the consent is carefully considered conveys an air of understanding and empathy. The perception of being rushed to “sign here” is not worth the few minutes it may potentially save.

Other situations can be anticipated at the time of consent and the family and patient prepared for eventualities unrelated to the complications or outcome. The simple suggestion that the procedure “normally takes 4 h” can be conveyed with the understanding that if the procedure is particularly difficult it will take longer. Conversely, a very short procedure will anticipate a very different outcome; usually in cancer surgery it will mean that the tumor cannot be removed. The patient and the family are then clearly prepared; should they learn that only an hour has passed and the surgeon is coming to speak with them. This is an important strategy when diagnostic laparoscopy precedes an intended complicated procedure. The setting of expectations cannot be overemphasized.

The potential for having to deliver bad news has begun at the initial patient encounter and at the time of informed consent.

The Family Does Not Want the Patient to be Fully Informed

The false belief that by not mentioning the word cancer the patient will be reassured or the family’s guilt assuaged should be confronted. For example, you come to see a patient. The family is hovering outside the room and begins with, “You know, doctor, he does not know he has cancer” and more concerning, “We do not want him told.” The truth is rarely that. The family does not want to discuss the frightening diagnosis, and rather than being reassured, the patient is often more terrified than justified. The situation has to be confronted with empathy and directness but absolute truthfulness.

Telling the truth does not need to be presented as a crucifixion. There are many strategies. From the simple as in my case, “Do you not think the patient knows the name of this hospital?” Or “Do you not think he knows what kind of surgeon I am?” Although seemingly more arrogant, “Do you trust your father?” followed by, “Will he be able to trust you if he learns that you have not been honest with him?” Or perhaps even more superficially arrogant, “Do you think your mother/father is intelligent?” followed immediately by, “Of course, you do. Do you not think he/she deserves the respect of his family?” There are many ways to address this issue. The importance is that avoidance of reality will only lead to difficulties in subsequent encounters.

Perioperative Death

In major operations, the potential for intraoperative or perioperative death should always be mentioned. The concept of “is there a risk of you dying?” can always be presented in the context of “of the last 100 patients undergoing this operation in our institution two did not survive the first 30 days.” This emphasizes the potential seriousness of the procedure without drama or inappropriate terror.

Intraoperative death is far less frequent today than it was 20 years ago. It is a rare situation where an intraoperative complication cannot be successfully managed to have the patient leave the operating room and be received in the postsurgery and anesthesia care unit. In that situation, the family can prepare at the bedside or nearby for an anticipated demise. Certainly, in a situation where a major intraoperative disaster occurs, the ability of one of the surgical team communicating to the family that difficulties have been encountered, and that they can anticipate the surgeon responsible speaking with them but not until the problem is addressed, is most helpful. This reinforces the importance of continued communication between surgical team and the patient’s family. The awareness of the patient and the family that there will be a nurse who will communicate with the family as to progress of an operative procedure provides an excellent resource. If the patient is aware that communication is available, then a wise surgeon encountering difficulty or even awareness that the procedure will be prolonged can have that communicated to the family. When serious life-threatening intraoperative problems occur, the ability to forewarn the family leads to a gradual anticipation of a potentially lethal event.

All of these scenarios are such that the delivery of bad news can be anticipated and planned for. The suggestion that the family be moved to a private consulting room ahead of the surgeon’s arrival provides similar anticipatory understanding.

When an Intraoperative Death Does Occur

When an intraoperative death occurs, it is essential that the surgeon responsible assumes that responsibility and discusses it with the family. The preparation of the family by giving them awareness that problems have been encountered is helpful. The invitation for the family to move to a private consulting room forewarns them of the gravity of the situation. It can be helpful to have the nurse who is dealing with the family accompany the surgeon to the family, but it should not be several members of the operating team who confront the family. This is the primary surgeon’s responsibility. This conversation does need to take place in a quiet environment with everyone sitting and composed. The initiation of the conversation can be difficult. Most often, the patient will be able to be resuscitated to where they will reach the recovery room. In that situation, the conversation can begin with, “Unfortunately, things have not gone well, and we have encountered a problem that is not solvable.” This can be followed by the actual description of the circumstances and must, if the anticipated outcome is demise, include a comment to the effect that, “We do not expect Mr. X to survive.” Such comments can always be tempered by a caveat as to the seriousness of the situation, the anticipation of permanent morbidity or organ failure if initial recovery does occur. Again, in the absence of absolute demise everything should be done to set the scene for the anticipated outcome. It is often most valuable once the anger and angst is tempered to suggest that you, the responsible surgeon, are going once again to see the patient and then will return to bring the family or the most closely associated members of the family to the bedside to reinforce the anticipated outcome.

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