Finishing up a consultation in the ICU, the nurses approached me to see how it went. “Did you get the DNR?” I explained that I enter these conversations without an agenda. My first goal is to develop rapport, reading the room to gauge how far I can take this conversation. What are they ready to hear? This phase of the consult is akin to preparing the soil for planting. The conversation is titrated as tolerated, watching for clues to see how it is received.
As a palliative care consultant, I am often in the position of balancing multiple expectations from the patient, family, and the primary medical team. There remains a lot of confusion among our colleagues as to the role of palliative care. During ICU rounds, I look for quick teaching points to add to the conversation, hoping to enhance the understanding of our work. I think of this as sowing seeds of knowledge.
I consider the unit of care to be the family; serious illness impacts the whole family. I inquire directly from the patient and family about their understanding of the medical status. It is not unusual for them to have different understandings. Much like plants that grow at their own rate, prognostic awareness evolves at a different pace for everyone. I make clarifications, planting more seeds to enhance their comprehension. I explore how far is too far? Are there any medical procedures or situations the patient would want to avoid? I have learned that there are a variety of things that motivate patients to try another round of chemotherapy or pursue a treatment or procedure. Often, they want to please a spouse, their children, or even their doctors.
When exploring goals of care with patients and their families, I present considerations like kernels and allow them to germinate. Before changing the code status, moving to comfort care, or hospice, I want them to feel heard, not pressured. I focus on listening, something I think is underrated but a powerful tool. Allowing someone to share their story, to bear witness to their challenges, is such a gift we offer. I have had staff tell me, “I didn’t really do much; I just listened.” I always remind them what a valuable role they have played. Listening is a way of nurturing the patient, like watering the garden, allowing them to bloom and express themselves.
I keep several motivational expressions taped to my workstation. They keep me connected to my purpose. One of my favorites is “Don’t just do something, sit there.” I don’t recall the origin, but it reminds me to invest my time and be fully present for them.
When I am inquiring about the patient and family’s understanding of the medical situation and uncovering their personal quality of life considerations, I remind myself, “It’s not about me.” I might choose something different for myself or a loved one, but the goal is to understand this patient, their needs, hopes, and fears.
I frequently hear from patients that they don’t want to be a burden to others. One of the most difficult burdens I witness is a family with a critically ill loved one who is no longer able to make their own care decisions. The medical team turns to the family to ask, “What should we do?” Frequently, I hear, “We have no idea; we never talked about these things.” This only intensified over the course of the pandemic as younger populations have fallen critically ill.
I also see our role as a source of support to our colleagues, whom I approach with the same empathy as I do our patients. I recognize the moral distress of those who worry about inflicting pain or discomfort on frail patients. “I don’t want to have to code her,” I’ve had a colleague say. I vividly recall the distress of another doctor sharing in the dictation room. Upon taking a report from the ER on his new admit, he turned to me, “I hope you’ll be available for this one.” “She’s young with cancer everywhere.” He was struggling; “What do I say to the family? I have a daughter the same age.” I assured him I would help, provided some conversation tips, and reminded him to take time for listening.
After a recent consult on the oncology floor, the staff was anxious to hear the outcome; they were concerned that the patient did not fully understand the implications of advanced cancer. During the interview, she opened up about a lifetime of trauma, going back to her childhood with an alcoholic parent, fleeing an abusive marriage, and surviving an armed robbery. It explained her strong faith that she would overcome this, having overcome so many challenges already. At the conclusion of the visit, she was moving through the shock. It seemed the medical knowledge was moving forward; some seeds were germinating.
I often conclude with a final question: “Is there something I did not ask that you want me to know?” Many are surprised and don’t have a response, but often they share an important nugget of information about themselves, a worry, or a priority not previously expressed. In the process of discussion, hidden concerns and preferences are exposed to the sunshine. Ultimately, I gain a better understanding of the patient, their quality-of-life priorities, and care preferences. Whether that results in a DNR or not, I have sown seeds of information and offered an environment for them to grow.
Aldebra Schroll is a family physician.