I’d like to say I seized the moment, that I responded brilliantly and my response prompted an open discussion about how she was doing. I wish I could say I didn’t hesitate or stumble. But her question caught me unawares, and instead I fumbled my way through. “You’ve told me you didn’t want any discussion about prognosis.” She nodded agreement. “I don’t.” Okay, I thought, we are back at baseline. As a way of obliquely answering her question, I reviewed her treatment and the objective and subjective assessment of her current condition. Again she nodded in what I thought was agreement. Until she asked another question, and I found myself flummoxed again, “Do you think I only have a few weeks to live?” Her question had a certain urgency to it, so I answered quickly. “No, no. That isn’t what I am saying;” which was true. Her cancer was advanced, but she was stable. There was a long and awkward pause before we returned to the conversation about her pain. I went back to my strategy of encouraging her to take the effective dose of medications for her pain. She smiled, accepting the information without returning to her difficult question. I waved as her husband wheeled her out feeling like I had just had the least therapeutic conversation with a patient ever. Ever.
I went through the rest of my busy work day, but it was one of those interactions I could not get out of my mind. I told the story to a couple of people, and we laughed nervously. I knew I could have done better. It is never easy to answer the am-I-dying question, even harder if you’ve been instructed by the patient not to go there. Overnight I continued to mull over the exchange and decided to take a second run at it.
The next day Cynthia’s pain was better and she was looking and feeling a bit more upbeat. I said to her, “I want to go back to your question from yesterday because I didn’t do a very good job of answering. Are you okay with that? ” She shrugged, nonplussed. She may have moved past the impetus for asking the question, but I thought attempting to revisit it was important so I pushed on. “I’m wondering if something happened to make you ask me that question because it surprised me after all the times you said you didn’t want any predications.”
Cynthia and her husband both smiled. I imagined they had discussed the awkwardness of the conversation. She said, “It’s just that you have been so attentive. Every day I come in and we discuss my pain. Plus, my son has been calling me more often. I thought maybe you weren’t telling me something.”
In all of my perseverating over what I had or hadn’t said to her, and how I thought I had not handled her question very well, I had not stopped to ask where the question came from.
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How do you respond to a patient who tells you not to discuss their prognosis?
Do you ever go back to a patient to revise a previous interaction, ask for a conversational “do over”?
Go to the bottom of the article to comment and share your thoughts about counseling patients and their family members in the final stages of life.