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The Boston Globe | May 2, 2012

By Kiran Gupta

In medical school, soon-to-be physicians are frequently required to take courses dedicated to improving their communication skills so that they are prepared to navigate emotional discussions about illness. I remember practicing giving bad news to a “standardized patient”—an actor who was paid to evaluate my empathy and compassion when I delivered the diagnosis of a terminal illness. While such training is valuable, nothing prepared me for situations in which physicians might feel hostility from patients or their families, or even be threatened with legal action. Our training and experience largely emphasize that communicating with our patients in an open and honest manner will provide the foundation for a trusting relationship as we work together to address their health needs. This is usually the case; perhaps that’s why we are ill-equipped to handle those situations in which a combination of genuine concern and the emotional burden of illness lead patients or their loved ones to challenge the care we provide.

Sometimes, as they should, patients and family members question the decision-making of their caregivers. Questioning is an essential part of understanding and we as physicians encourage those we care for to be well-informed. Rarely, a patient or family member will try to pressure a physician to proceed in a manner the doctor does not deem appropriate. No matter how much duress a doctor faces in such circumstances, his or her highest obligation remains to provide clinically sound care based on the best evidence available. This can seem difficult when confronted by a frustrated patient or angry family. Though physicians are not required to proceed with tests or treatments that are not clinically indicated – doing so can often do more harm than good – the pressure to do something more is especially great when patients cannot advocate for themselves, leaving anxious family members to drive the dialogue regarding care.

Several months ago, our medical team was confronted with just this type of situation. We were caring for a woman suffering from a widely metastatic cancer. Her disease was non-operable and the oncologists had expressly stated to the family that no further treatment was warranted other than to manage symptoms. She lay in her hospital bed, moving minimally and barely communicating. Her eyes would intermittently open. She appeared uncomfortable. To our team, the prognosis was clear: the cancer had ravaged her body, and it would not be long before infection or bleeding ended her life.

Yet one of her family members remained unconvinced. Despite numerous CT-scans and MRIs depicting the tumor making its way into her major blood vessels and wrapping itself around her internal organs, he insisted that the patient was dying not from this aggressive disease, but rather from an entirely unrelated condition. He demanded that we perform additional tests and provide a treatment that he had read about on the Internet. He even threatened legal action against every doctor in the hospital who had been involved in this patient’s care if we failed to proceed as he felt we should.

Each of the doctors involved was certain that this patient was dying from cancer and that no additional diagnostic test or treatment was needed. How, then, should we handle this questionable information from an uncertain online source? Should we order the additional tests to pacify the family member? That clearly didn’t seem right. After spending several hours talking it over with a few senior physicians, we decided that nothing further should be done.

The next morning, when it came time to explain to the patient’s family member that, in our collective clinical judgment, further treatment was unwarranted and the information he had relied upon was unsound, the situation was tense. He angrily threatened to go to court later that day if we did not do as he wished. The hostility was overt. I was acutely aware of my own apprehension as I stood in the patient’s room, watching the relative scrutinize our every move. Though concerned that our interactions with the patient might be misinterpreted or misconstrued, it was our duty to examine the patient and continue to care for her.

In these situations, family members may believe they are advocating for their loved ones. But an antagonistic approach places physicians – consciously and subconsciously – on the defensive. It creates distance between patient and caregiver, sometimes leading to decisions that may produce less than optimal care. Most unfortunate is that, in such tense settings, the patient no longer remains the center of attention.

The family member’s threatening demeanor had pervaded all aspects of our patient’s care. Meanwhile the patient lay in bed unconscious. We knew that she would likely not survive the day. She was bleeding and her breathing was labored. Gently, our team explained to the family that the situation was grave. We were met with a silent glare. Later that morning, our patient succumbed to infectious complications from metastatic cancer. Sadly, after she died, her family continued to threaten legal action and our focus shifted to the mountain of documentation and legal paperwork that had burdened her care in these final days. I hoped that at least she was at peace.

As physicians, we are not trained to understand the legal nuances of certain complex situations that we may encounter. We are often told that as long as we communicate clearly and well, provide the highest standard of care available, and demonstrate compassion, we are doing the right thing. All of this is true. But standing at the foot of a dying patient’s bed, facing a visibly angry, grief-stricken family member who is threatening legal action can make it extremely challenging to provide effective, patient-centered care. Perhaps we should know better than to take such threats too seriously. But that, it seems, asks too much. Physician behavior is undoubtedly affected when legal threats are made, which raises difficult questions about the litigious environment in which we currently practice.

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