“I couldn’t believe the surgeon was so upset! The patient was 80 years old, he was frail, and he didn’t want major surgery. He just wanted medications for his bowl obstruction (that is, blockage in the intestine) and die without suffering Sounded reasonable to me,” the hospitalist exclaimed as he described a recent encounter with the surgeon on call at his hospital (a hospitalist is an internal medicine doctor who sees a patient on behalf of their primary care physician when the patient is admitted into the hospital).
I relayed this story to a good friend, himself an eye surgeon, trying to convey how much the hospitalist - and I as a palliative care physician (read Post 1: What Exactly Does a Palliative Care Specialist Do?) - had not understood why the surgeon had become so upset with his patient. “The gentleman weighed the pro’s and con’s of this big surgery and decided the potential risks and burdens weren't worth it," I said.
“Actually, I agree with the surgeon,” my friend said.
“Oh?” I asked.
“Yeah. As a surgeon, your professional mindset and livelihood is a ‘fix it if I can fix it’ mentality. If there’s a procedure that I know will prevent someone from going blind, and they refuse the procedure, I'll likely get upset because I know the repercussion of not doing the procedure is pretty severe. If there’s actually a workable solution to prevent that repercussion, of course I would feel frustrated if I'm being prevented from helping! And in the case of the general surgeon, he was offering a potentially fixable solution to a problem where the repercussion of not implementing that solution was likely the patient dying. That's no small deal!”
Tough medical situations often involve strong emotions and high stakes decision making. Palliative care physicians try their best to support everyone involved – the patient, anyone whom the patient considers family, the nurses directly involved with caregiving, and the healthcare providers themselves.
However, in the process of trying to be strong advocates for their patients and family members, palliative care specialists may sometimes identify with or prioritize their patient’s and family member’s concerns and emotional states over their colleagues’ concerns and emotional states.
For myself, the perspective provided by my eye surgeon friend was indeed enlightening, and I thought of other examples in which healthcare providers have disagreed on recommended treatment plans, all in the name of proposing what they thought was “best for the patient.”
An ICU physician once requested, “Palliative care team, can you please talk to the family for room 308 about their goals of care (read Post 54: Why Should I Care about My 'Goals of Care?')?”
“Sure,” my team replied, “What’s going on?”
“We had just finished speaking with the family about this patient’s multiple failing organs and how his prognosis for leaving the hospital is very poor, but then the nephrology team came through shortly after us and apparently they offered the family dialysis, which the family accepted! Please talk to the family about their goals.”
In this instance, “please talk to the family” was code for “please talk to the nephrology team – and other specialists on the case – and assess what the family understands. We do not have the time to coordinate all of this today and/or the family needs an independent party since we and the nephrologists are not on the same page.”
The ICU team was clearly distressed, and in this situation, it was a matter of supporting both the family and the primary ICU team.
After speaking with the nephrology team, the palliative care team was able to meet with the family and in the course of the meeting, explain why “the doctors say things that contradict each other!”
“We spoke with your ICU team, and we spoke with the nephrology team. It sounds like the ICU team stand by what they told you earlier, which is they’re worried that your father may die in the ICU regardless of what they try because of his multiple failing organs. They’re worried that the organs are going to continue to fail – or at least not improve back to an independent working state – because of the amount of life support medications and machines his body is already requiring.”
The family members somberly nodded their confirmation on having heard this news.
“And it sounds like the nephrology team’s reasoning in offering dialysis – which, remember, is not a cure for kidney failure and instead a machine that acts like the kidneys when someone’s kidneys have completely failed – is that if they can sustain the kidney organs for the next several days perhaps they can buy time for the other organs to turn around.”
“Ohhhhh,” the family members responded, “That makes sense. But the ICU team doesn’t think dialysis will make a difference?”
“No, they don’t,” the palliative care team replied, “So just like you can have two different highly specialized experts disagree on the best phone to buy, the best way to bake a potato, or the best investment methods to follow, so you'll find the same in medicine. You will sometimes encounter two highly experienced, highly trained, highly skilled specialists with different perspectives and therefore give different recommendations about the same situation.”
After a long pause, a family member asked, “Well, what do we do then?”
And the answer to that question are my suggestions to you if you were to ever find yourself in a similar situation (that is, different doctors providing seemingly conflicting recommendations):
1. Find out the “why” behind each doctor’s recommendations.
2. Find out the realistic potential benefits (“What would be the point of this medical treatment you propose?”) and the realistic potential burdens (“In what ways would this medical treatment you propose affect my day to day life?”) for each treatment path.
3. Setting the above aside for a moment, articulate your own values and realistic goals. What is most important to you at this time? What at a minimum is necessary for an acceptable quality of life (read Post 7: I Want the Best Care Possible for ME – Part 1 of 2)?
4. Determine which potential treatment risks and burdens would be unacceptable to you, and determine if the potential benefits of a proposed treatment path (and remember, choosing to simply monitor can often be a viable treatment path) are enough to outweigh these risks and burdens (read Post 16: Medical Decision Making 101).
5. Consider asking if it is possible for a proposed treatment path that you and family are undecided on to be trialed for a short defined amount of time (read Post 69: 6 Reasons to Trial the “Time Limited Trial”).
6. Know that you can only make the best medical decisions that you can with information you have at the time. Know that no matter the outcome – good or bad – that the outcome is not anyone’s “fault.” Sometimes, our or our loved one’s disease, illness, or medical condition changes in unexpected ways despite the experts’ best predictions and your advocacy for the best care possible for you or your loved one.
I hope these suggestions help decrease some of the frustrations you may feel if it seems as if "none of the doctors are talking to each other."