Issue 23 / 24 June 2013

WHEN we enter medicine we have romanticised ideals of curing every ailment, and sending patients home happy, healthy and supported.

It’s during our formative years as a doctor that we will sometimes experience the futility of medicine and the frustration at being able to do little or nothing for our patients.

These patients’ names may disappear in the bustle of busy life, but their stories and faces stay with you.

I met Mr K during a surgical rotation. He was in his early forties, with two small children and a loving wife, and a large extended family. He was a delightful patient — upbeat and positive, friendly and talkative — despite his recent diagnosis of pancreatic cancer.

He stayed at the hospital for quite some time and became one of our favourites.

The clinical team explored different possibilities for treatments and different avenues to extend his life, but ultimately there was nothing we could do medically or surgically to remove the cancer or prohibit its advancement and spread.

I was present when the surgical fellow broke this news to him. It would have been a hard conversation for both of them, but the way Mr K took the news was a reflection of how he had lived his life — honestly and bravely. He cried openly, but he was not angry and resentful at the world, just filled with sorrow.

I felt angry and powerless at the time. I asked the surgeon what can be said to someone who faces imminent death, leaving behind small children and a family. “People always need something to hope for. If you lose your hope then you have nothing”, he told me. He was right.

At the beginning of a disease patients will hope for resolution, cure. But as disease advances they will hope, for example, in cancer, that it doesn’t spread. When there is poor prognosis and imminent death is inevitable they may hope, for example, to see their daughter get married, or their grandchild’s 2nd birthday. Nearly all hope that their last days will be calm and pain free and that they will die a peaceful death surrounded by family or somebody who cares.

So the focus of hope must shift as the disease state advances.

I now understand that the worst thing you can say to a patient is “we can do nothing more for you”, as you deprive them of hope for the future.

Another patient, Mr B, was 51 years old and had been diagnosed with Huntington’s disease 5 years earlier. Previously a high-functioning insurance broker, with a family and teenage sons, he now lived in a share house and had been dependent on alcohol since his diagnosis.

He was seen after a fall and with confusion. Although all brain scans had been normal, we thought it best to admit him to improve his social circumstances, alcohol misuse and other issues.

He told me he had not seen either of his sons in 3 years. When I asked him to show me his teeth he laughed. “I’ve spent so much money on my teeth in the past”, he said through his partially toothless smile. “And what for? Nothing will change, it’s all useless. Even coming into hospital is useless for me.”

I wondered if, faced with a deteriorating neurological system, depression and dementia in my mid-forties, I too would be driven to drink to numb this realisation, and I was overcome with pity for him.

I struggled to respond in any meaningful way to his statement, as on some level I agreed with him, and understood what he was saying. This man evidently had lost all hope for his future.

During training we gain a vast amount of clinical and theoretical knowledge — we know how to take histories from patients and how to examine them, what investigations to do and what medications to prescribe. These concepts are drilled into us over and over again.

Yet, it is the therapeutic relationship and how we interact with our patients that allows us to understand an individual patient’s narrative — to conceptualise the disease process within their social and cultural identities and their every day.

For each patient there must be something that we can give them to hope for. Perhaps as doctors that is our greatest challenge, but also our greatest privilege.

Dr Michele Bardin is a resident with Austin Health in Melbourne.
 

11 thoughts on “Michele Bardin: The power of hope

  1. Kingsley Whittenbury says:

    Great article Michele, Acknowledging and sharing hope is an aspect of empathy that, I know as a patient and a doctor, matters. I will share this with my medical students.

  2. Atoosa says:

    Very true..

    I think that most doctors are that negative because of medico legal ramifications too.i.e…a patient might sue if you tell them you can live longer  etc and the angry family are then after you that why did you say such a thing.. And raise hope for nothing.

     

  3. catherine stuart says:

    Beautifully written Michele. I wish we had had such a topic in Med School. Perhaps now students are more enlightened with regards breaking news etc. I remember my Dad’s face and demeanour when the treating surgeon told him he had a metastatic hypernephroma and there was “nothing more he could do” and that he probably would not see Christmas. He almost turned his face to the wall after that. My brother and myself, who are both doctors, nearly collapsed too. It was as if the ground had shifted under us all and we all went white. It was exactly as you said, the banishment of hope. It is part of our Hippocratic Oath …to relieve always.

  4. Dr Richard Shiell says:

    These are difficult discussions and without telling the patient a lie you can say

    “Yes your condition is serious but no-one can say precisely how many months or years you have remaining.  Many of us now fit and healthy may go before you do, so make the most of every day remaining”

    At 75 years of age, how many times I have seen the truth of this last statement with apparently healthy colleagues dying withing a few months of our last meeting , yet some lung caner patients surviving 10 years.

  5. Anthea Condilis says:

    Thanks Dr B.

    “I wondered if, faced with a deteriorating neurological system, depression and dementia in my mid-forties, I too would be driven to drink to numb this realisation, and I was overcome with pity for him.”

    It is MY hope that all doctors think the same way you do. All people (even the toughest of doctors) have a tipping point. But a caring doctor can help tip those feelings of futility back towards hope. Purhaps it is only in the extreme cases of pending death, that we are better reminded that we also have a mind to heal.

  6. Sue Ieraci says:

    We tread a fine line between facilitating some sort of hope for the future and providing false hope of a medical cure. In my view, there is a lot we can ”do” for patients that doesn’t involve medical therapy – whether it is physical or emotional comfort, food and warmth, or just respect.

  7. Andrew Nielsen says:

    Good article.   

  8. Department of Health Victoria Clinicians Health Channel says:

    Nicely written.

    Depending on the specialty you work in you’ll see death with greater or lesser frequency. I don’t believe you can continue to have the degree of honest empathy that you have in your early years of training. So I think it’s necessary to be good at displaying sympathy without needing to have such empathy, or else you’ll end up hating the world. It’s difficult to teach how to keep the right distance, how to accept that you often can’t help, or even offer hope. And in breaking bad news it’s hard not to feel that you are taking hope from them, but it’s clearly not the case.

  9. Department of Health Victoria Clinicians Health Channel says:

    A good article but a few extra words need to be said.

    We all die. Doctors need to learn to allow people to do that and not feel personally affronted or guilty about it.

    Doctors are not God and they are not the sole carer of any patient. If a doctor forgets that he is only one member of a bigger team then the patient ‘will’ suffer.

    There is ‘never’ “nothing more that can be done” – but it might not be the doctor who does it. It’s good to read comments to this effect.

    “Yes your condition is serious but no-one can say precisely how many months or years you have remaining.  Many of us now fit and healthy may go before you do, so make the most of every day remaining” —  This statement from 75 y/o Dr Richard might have been acceptable back when he was training but it certainly isn’t any more. It might be literally true and it might give the doctor saying it some sort of comfort or ability to deal with a dying patient. But it is really, ‘really’ patronising in this day and age. Patients know when they’re dying and don’t need that sort of pap dealt out to them.

     

  10. Department of Health Victoria Clinicians Health Channel says:

    Every one likes to live one more day, it does not matter how old – 40-50-60-70- years old – every one asks for one more day, but we cannot have it. This is the Law

    When we are at the end why we do not use the power of gratitude for what we had in life.

    to see every morning the sun rise  and warm our skin

    to see the face of our partner and kids when they smile

    to be grateful to our parents that give to us life

    to remember our friend/colleagues and everyone who helps us to became a better person…….

    I do not known if this can be a relief…….I am not there at the moment ………..I will in the future…

     

     

     

  11. auspsychiatry.WordPress.com says:

    Great article and the way you handled these situations was with thoughtfulness and sensitivity.
    Empathy,compassion,providing hope,and good interpersonal skills are just as important in practicing medicine as diagnostic skills.

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