Dr. Devapiran Jaishankar, MD has been an Oncologist in Tennessee for 10 years, and spent 10 years prior to that working as an Internist. He brings great insight to terminal diagnosis discussions with patients and their families.
Dr. Jaishankar was candid, yet thoughtful in his responses, describing the most important question we sometimes don’t ask patients and their families in illness is “what are your expectations?”
In his experience, most physicians in adult medicine shy away from these discussions because they aren’t well equipped; they aren’t trained to have these discussions; they feel overwhelmed and defeated. The barriers also come from the understanding of oncological conditions lacking depth (in general medical education). For instance, a stage for a patient may be terminal, but it could also become a chronic disease to live an additional 1-10 years depending on the disease state – they are terminal, but also not terminal.
I can have these conversations with families, but the hardest ones are with my brethren and colleagues. I often have to ask “why aren’t we having the Hospice and Palliative discussion?” I feel the Oncologist or PCP are the two most valuable people you can use in leading these discussions because we have such established relationships with patients. The easiest thing is to receive a consult from a Hospitalist because they need some help in having these discussions. The smartest thing I can do is to educate the Hospitalist during this process.
In discussing breaking bad news, Dr. Jaishankar offered a scenario. Say for instance there is a lump in a breast, it’s biopsied, and it’s cancer. Breaking the news is hard, saying the word “cancer”, and then they hear nothing else. From there, it’s a lot of logistics and decision making; along with the narrative, it overwhelms the patient, according to Dr. Jaishankar. Once those words are spoken, you’ll see everything from primitive to advanced methods of coping when you break this news from anger, resentment, denial all the way to reading 40 pages of literature and bringing all of that to the next appointment. Regardless of the patient’s coping mechanisms, one thing remains constant, which is how important time is in the process. Dr. Jaishankar schedules his first appointments when news is broken as 60-120 minutes.
Never BS them in these moments, though, according to Dr. Jaishankar. If you don’t know, tell them you don’t know. The lab results or imaging may not be in front of you. That’s ok. Don’t blame other departments like CT or the lab.
You have to be very patient, but in that encounter, you will have a moment and a time will come when the patient will look up and make eye contact; he’s reading you and wondering if he can trust you, “is there anything you’re hiding, are you accurate in what you’re saying?” You have to be as open and honest, transparent in that moment, and seize it, because you will not get that again. They have likely heard nothing other than the word ‘cancer’ leaving your mouth, but this is the single moment you two will have an opportunity to communicate meaningful information. You need to ask him then, “what do you need from me right now?” Are they ready to accept it? They don’t want to hear that CT report in your hand, because it adds up to the stage 4. Slowly lead up to what the scan means.
On the same note, by hiding behind the CT report and not seizing these moments, this is how we as providers use defense mechanisms in dealing with death and dying. You may stave off your own guilt or an uncomfortable feeling in doing so, but patient care suffers in the process. Remember, medicine is about being comfortable with being uncomfortable.
Use your common sense and wait for that right moment. Sometimes you have a checklist and things you have to do, but you need to be patient. It may be a 60 minute visit and the moment may not come until the 53rd minute. A lot of people understand what stage 4 and incurable is, but they hate hearing timelines.
I tell them I believe in God, but I’m an instrument and the executer of the plan at hand. I say “I get asked this a lot, so I need to be honest and give a time range for you so you have the information available. It helps us figure out how we play defense. However, never have this discussion in the first meeting, unless they ask. You must wait to give the timeline until after you’ve broken the news, most often at a later appointment. It’s important, but it’s also very dangerous, because their take home message is there’s a clock on the wall, and they have to live according to that clock – as though there’s a death clock ticking away and they’ll die when it hits 24 months.
The Football Analogy
Dr. Jaishankar has a great visual everyone can connect with and see. Imagine someone is stage IV – we’re playing defense at the 30 or 40 yard line. In this situation, there’s hope and there’s hype. You have to walk the line and balance both. You don’t want to take hope away or deny the hype that can be there, because family spirits can be lifted by both. You’re playing defense, and you can pick your yardage based on the cancer or diagnosis. Dr. Jaishankar says,
I’m going to do this treatment, and eventually it will outsmart me, so it pushes us back to the 20 yard line, but I have second line treatment, and in this, we might be able to push the ball back to the 30. We can’t beat it, but we can march back. And then we play defense at the 10, and finally the end zone. That’s when the man will lean forward and ask what that means. I tell him that it does mean death, and at that point, I cannot cure you, but I’ll always be honest with you when we reach that end zone or are near. I will tell you. My whole goal is to help you do your life, live it how you see fit, and have the most quality you can while still playing defense and fighting.
In terminal diagnoses, there is often more time in the front than near the end zone, and treatment goals revolve around doing everything to stretch that time while patients are still up and enjoying life, seeing concerts. Things get tougher near the end zone, where heroic measures can shrink instead of stretch time like they might while still at the 30 yard line, actively playing defense. Dr. Jaishankar adds when discussing with patients,
For us to add tube feeds at the 10 yard line, then yes, we’re playing good defense, but am I helping you as a patient? I’m just prolonging the symptoms you’re experiencing. We try to not stretch time at the back end. This is where we discuss DNR, intubation, TPN, IVF, tube feeds, etc. We’re here to serve them, and they drive the bus. I say simply, “How can I help you drive this bus?
Incorporating Personal Beliefs
Patients don’t want to know who you are or where you’re from, but they do want to know philosophically what you think as a provider. You have to tell them what you can and cannot do.
Osler said “religion and politics have no room in the hospital. You’re there to take care of them.” However, we live in different times where patients often lean on us in how to move forward in end of life care issues. Patients want our guidance, yet we don’t want to give biased medical advice – it’s a fine line, but one that can deepen relationships with patients. Don’t be so ashamed to let people know how you feel. Put your heart on your sleeve in medicine. Your patients will relate to you more because of it.
May your words be kind, gestures gentle, and compassion at the peak of your emotional capacity as a human when talking with families in these moments.