How Palliative Care Helped Improve my Patient Care

One of my favorite parts of medicine is getting to speak with patients and their families. The privilege of interfacing with patients is predominantly why I chose medicine; I enjoy talking to patients not only about what brought them to the hospital, but also the things at home they look forward to returning to after discharge. I remember a week on my general medicine clerkship where I was late for rounds several days in a row; each day I’d catch up with the team just as they were setting off from the team room, saying “sorry the patient was chatty!” By the third day I realized I had said that about three different patients, and the limiting reagent was probably me.

 

But while talking to patients is enjoyable, I found myself always gravitating towards happy subjects. Like the plague, I avoided more difficult subjects and bad news of all sorts. I have somewhat of an innate tendency to be a “people pleaser,” which sometimes causes me a good deal of personal stress from being unable to say no. I’ve always felt it was absolutely worth it to just do something rather than upset someone by explaining that I’m too busy or not interested. This habit has been problematic at times in the hospital as well, where bad news can be common and my inclination is to always answer in the affirmative. (Example: “Sure, it’s possible that you could be ready for discharge tomorrow!” — I learned early in third year that patients better be actually ready for discharge before you start suggesting it.) To address my fears of delivering bad news I forced myself to sign up for the uncomfortable realm of palliative care, a rotation I completed in August of this year.

 

Going in I was very nervous, I honestly hadn’t seen anyone die at all during my third year, and I had stayed away from very sick services such as heme-onc on purpose. Being rather uncomfortable with the idea of death myself, I wasn’t ready to discuss it with anyone actually facing it anytime soon. I started the rotation on the main hospital palliative care consult service and felt immediately more comfortable after meeting the team. There were a lot of people involved, including an attending, fellow, nurse practitioners, and chaplains, and everyone was so warm and welcoming. I was prepped with a brief discussion of common consults that might be seen on the palliative service, and the conversation tools used by palliative physicians to talk to patients about difficult issues. I found it helpful to learn that there was a sort of “toolbox” of conversational techniques, and the most important part of the palliative job was to listen to the patient to decide which one of the tools should be used. An end-of-life conversation was viewed as something of a therapeutic procedure, which allowed me to conceptualize our role in this process better. After just a few days observing conversations between the attending or fellow and patients and their families, I gained an immense appreciation for the work that they do.

Some of my palliative care notes, kept in a small notebook I carry in my white coat.

This experience helped me realize that sugar-coating bad news doesn’t do much of a service to your patients. I saw patients with end-stage liver or kidney disease who were shocked to hear how grim their prognosis was. It floored me to imagine all the encounters they’ve had with medical personnel, and yet they somehow still didn’t understand how sick they were. Part of this, I learned, was simply a defense mechanism of the patient, who had been told but wasn’t ready to confront the severity of their illness. But another major part was the myopic view often taken in the hospital of patient care; we spend day after day on the inpatient services presenting one small problem after another, assessing the status of that problem and the plan to fix it. Leukocytosis, stable. AKI, give fluids. Anemia, continue iron supplementation.  While that helps us be thorough in the problems we treat, I’ve seen that at times this approach might cause us to miss the overall picture. “Patient has liver cirrhosis causing ascites, hyponatremia, and hepatorenal syndrome.” The team might understand that this is a bad prognosis, but we don’t always do the best job expressing this to our patients. There may be a plan in place for every small problem, and we sometimes use this to hide the fact that there’s nothing to do for the overall clinical picture.

 

One reason I seek to avoid delivering bad news is the emotional response that may inevitably be elicited, it’s inherently uncomfortable to see someone else cry. It can be scary to be around someone who is angry. My palliative care experience allowed me to work on this too by teaching me that such an emotional response from the patient means they get it. They heard what you were trying to tell them, they understand the meaning of the bad news you just delivered. And though it isn’t easy, and though you might need to give your patients time to emotionally process, once they have processed things then you can work together with the patient and their family to move develop a plan for moving forward. You can trust that the patient fully understands, and only with their full understanding can you begin to provide patient-centered care.

Following this rotation, I have found that I feel more confident in my patient care interactions and I now consciously make an effort to identify when my own bias to lean on good news might be masking the gravity of bad news. I focus on looking at both the individual problem list as well as the big picture for patients. Finally I try to be a better listener for my patients; palliative care has shown me that the things patients say might not really reflect what they mean. A patient’s question about statistical prognosis may actually be an emotional response to a cancer diagnosis, and it will serve them better to respond with an empathetic emotional statement rather than drilling numbers.

 

Going forward, my goal is to continue to practice these palliative care skills when opportunities arise. Throughout the end of fourth-year, this will best be accomplished with the support of my senior resident. When bad news needs to be shared with one of my patients or their families, I plan to run through my conversation with my senior beforehand, and ask them to come with me into the room as back-up. I will follow the tools I learned in palliative care, including reflective listening, reframing, empathy, and allowing for silence. At the end of such encounters, I will debrief with my resident, and ask for feedback on what went well and what could have gone better. As I become more comfortable with these skills I can work with my senior to start to cut back on some of the safety net that they provide.

 

I am extremely grateful my experience on palliative care this past summer. I know that delivering bad news will be a necessary part of my medical career as well as my personal life, and I feel it is very important for me to be able to do this in a way that is supportive for my patients.

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