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Correction

Caring and compassion:
crucial for our profession

by: LAWRENCE M. SHUER

Recently, the hospital's interim COO Mike Peterson and I met with a family whose experience here was clearly less than optimal, and I'd like to share with you their concerns. While the summary below is information shared by the family incorporating their perceptions of our medical staff and system process, I believe it can serve as a valuable lesson about the importance of good communication, compassion and coordination of care.

* * *

The patient was a man in the prime of his life who had been transferred to Stanford with a rather advanced cancer. As a result of his condition he had liver problems that led to a coagulopathy. According to the family, on the first day of the patient's stay, his wife was told that it was unlikely her husband would make it through the night because of a lab value that was so abnormal it seemed inconceivable he would survive. It turns out the lab value was wrong and the patient did, in fact, make it through the night.

This did not negate the fact that the man was gravely ill, however, and the family felt they were subsequently not given information indicating that he was unlikely to survive the hospitalization. A series of further evaluations disclosed "spots" on the liver, but the family was not told that these were likely to be part of the tumor.

There was debate among the consulting physicians as to whether the man should undergo a trans-jugular liver biopsy. When the decision was ultimately made that it was clinically appropriate to proceed with the procedure, the family reported that their feelings of anxiety and frustration were heightened when they were not informed of this decision.

After the procedure, the patient's wife asked about possible complications that could occur. She was told that he could bleed into his abdomen, and she also said she understood that she was to watch for any signs that his abdomen was becoming hard. Soon thereafter a team of ENT physicians performed a biopsy of his nasal mucosa at the bedside to determine whether he had a fungal infection, as he was immunocompromised and was having fevers of undetermined origin. Two biopsies were needed because the first yielded insignificant tissue.

Despite nasal packing, the patient began to bleed from his nose in such quantity that he began to cough up blood. The family told Mike Peterson and me that they found themselves having to suction him to prevent him from "drowning in his own blood." One of the patient's relatives was in the medical field and requested that the patient be transferred to the intensive care unit. Initially this did not occur because the patient's vital signs were reported as stable. Ultimately, elective intubation was required to protect the patient's airway. He was transferred to the ICU where, after an attempt at improving his condition with chemotherapy, support was withdrawn and he expired.

* * *

This story is obviously from the perspective of the family, but I think it's important that we consider this information and learn from it because I believe we could have done better in supporting this family through a very difficult time.

While the outcome of this case might not have been any different, there were multiple points in the patient's care at which communication could have been better, and more compassion for the patient and his family could have been demonstrated.

Sometimes it seems as if no one person takes charge of a case, and we end up with patient management by committee as multiple consultants become involved. We must remember to consider how we're perceived by patients and their families. In this case, the family expressed that they felt there was no single physician on whom they could rely for information until he was in the ICU and the intensivist served that role. For some reason, case management and social work were not involved in this patient's care, but that doesn't excuse the resulting perception held by this family - mainly, that our physicians have poor communication skills and lack compassion.

Physicians are supposed to be healers, but sometimes we're faced with situations in which the patient's condition is bad and so is the prognosis. Particularly in these cases, certain communication skills are required in speaking with patients and their families. We must strive to improve these skills and teach them to our house staff.

We are not always able to conquer disease, but we should be able to demonstrate compassion and caring to our patients and their families. Any of us who has been a patient or has had a hospitalized family member can empathize with the family in this story. Remember: The first element of our mission statement is, "To care." Let us strive to do that in each of our patient encounters.

If you have suggestions, questions or concerns, please call me at (650) 723-5371 or write: lshuer@stanford.edu.