INDEXING TITLE: RCHAN’S MAR [5-02]

TITLE:  Bad News

PERIOD OF MEDICAL OBSERVATION: March 2005

 NARRATION:

            My patient was a 50-year-old female who sought consult December of last year because of obstructive jaundice.  Ultrasound of the hepatobiliary tree and pancreas revealed a contracted gallbladder with no lithiasis. Common bile duct was non-dilated. Liver was normal. Pancreas was noted to have a mass 4 x 4 cm.  We requested for CT scan of the abdomen which revealed a lobulated pancreatic head mass of the same dimensions.  Same findings were noted of the hepatobiliary tree. We referred the patient to our service consultant who advised an ERCP. The patient however, due to financial constraints was unable to raise enough funds for the contemplated procedure.  She was lost to follow-up.

            She came back this month with more jaundiced, with significant weight loss, anorexia, on and off abdominal pain, tenderness in the epigastric area with occasional fever.  On physical examination, the abdomen was enlarged, tender at the epigastric area, with a markedly enlarged liver and positive for fluid wave. We suspected her to be cholangitic at the time of consult.  A repeat ultrasound was done.  Unfortunately, it revealed the presence of  an enlarged liver with multiple  hypoechoic nodules.  We decided to address the cholangitis of the patient by decompressing the hepatobiliary tree on an emergency basis.  We prepared the patient for operation.  I informed her daughter of the plan. I however, emphasized that it was not for cure and just for palliation.  Her mother is terminally ill and no matter how we deal with her present problem , the endpoint would still be the same…INEVITABLE DEATH.

            Upon opening up, ascitic fluid poured out of the abdomen.  Indeed the liver was enlarged and studded with nodules.  The gallbladder was contracted and hard, with note of extension of the tumor.  The pancreatic mass was as large as a softball, adherent to the hepatoduodenal ligament and the gallbladder and was fixed to the retroperitoneum.  There was no way that I could expose the common bile duct to put a tube in it.  In other words, it was an “OPEN and CLOSE” procedure. 

            I requested a meeting with her daughter after the operation and informed her of our findings. I regretfully told her that even putting in a tube within the common bile duct was impossible.   I explained the extent of the disease and what she can expect for the next few months.  I felt an ache in my heart as I told her that she can bring her mother home after the operation and take good care of her.  I advised her to relish the last days of her mother’s life and make it fruitful.  With a lump in my throat, I conveyed to her that we cannot do anything more for her, save for to offer her prayers.  All the while during our conversation, her daughter was crying and I could not help to be teary-eyed as well. For I too am a daughter and I felt the pain of her going through the thought of  losing a loved-one.  I asked her if she wants me to break the news to her mother personally.  She declined.  I tried to convince her otherwise but to no avail.

            For the next few days, as I did my rounds on my patient, I felt a pang of guilt.  There she was a lot more cheerful and energetic prior to her operation, as if she was finally cured of her illness.  She kept on thanking me for everything when at the back of my mind I actually did nothing…

INSIGHTS: (discovery, stimulus, REINFORCEMENT, physical, psychosocial, ETHICAL)

            Death is an unevitable part of life.  It is a difficult task for every physician to convey the news to their patients that they are terminally ill.  Most of us would feel that giving such an information to their patients would adversely cause a strain in the physician-patient relationship and consequently give the patient emotional distress. 

            Contrary to popular belief, patients would actually want their physicians to reveal the truth about their condition.  It fosters trust and demonstrates respect to them as human beings. Patients should be told all relevant aspects of their illness, including the nature of the illness itself, expected outcomes,  treatment alternatives and their risks and benefits, and other information deemed relevant to the patient’s personal values and needs. Complete and truthful closure need not be brutal and should be tactful. We should be sensitive to the patient’s ability to digest complicated or bad news. If the physician has some compelling reason to think that disclosure would create a real and predictable harmful effect on the patient, it may be justified to withhold truthful information.

            What if the family wants to withhold the truth from the patient?  Their motive may be admirable. They just want to spare their loved ones the potentially painful  facts about their illness.  We as physicians should convince them that disclosure will be done sensitively and tactfully to allay their fears.  However, if they divulge anything that indicates that the revelation of the information can cause harm to the patient, withholding information may be more appropriate.

            There are two main situations that it is justifiable to hold truthful disclosure.  First is when it would cause harm to the patient. An example would be a patient who became depressed due to the news of a terminal illness would be potentially suicidal.  The second is when the patient himself/herself expressed an informed preference not to be told the truth. Another special situation is when a specific cultural or religious background would have a different view on the appropriateness of truthful disclosure. 

            It takes years of experience to be able to confront a patient  and his/her relatives and boldy but delicately deliver the unpleasant issue of impending death.  There are some pointers to remember in priming the patient and the relatives:

-          Plan what you will say to the patient.

-          Determine what the patient knows about his illness.

-          Find out how much the patient wants to know about the diagnosis.

-          Deliver the bad news.

-          Respond to the patient and family members’ feelings

-          Inform them of your plans and follow-up.

In retrospect, should I have been honest enough to my patient? Should I reveal to her the painful truth  about her terminal illness?  Do I have enough guts to tell her that I failed in her expectations? Or am I saving her from the potential harm that may arise from her knowledge of  the inevitable…DEATH.