Doctor tells patient he doesn't have long to live through video screen
ktvu.com
ktvu.com
There's a right way and a wrong way to talk to someone about their death. The right way involves making eye contact, making sure that they can hear you, and if they are comfortable with it, holding their hand.
The wrong way involves doing none of those things, because you are talking to them via a shitty Skype connection on wheels.
Technology has a huge role to play in healthcare. It's invaluable in diagnosis and treatment. In the long run it'll probably put a lot of people who do those kind of things out of work. But it should not be used to replace the empathic, emotional aspects of healthcare. If anything, the labour efficiencies generated by technology ought to increase the resources put into empathy -- not be used to eliminate it.
That being said - I agree that the empathetic and emotional aspects are lost when communicating remotely. Heck, I already feel that even in a work setting. It’s hard to imagine what it would be like when handling a crisis.
The OP article describes a situation where the patient is waiting in the intensive care unit.
If my time on this earth is now measured in hours or days instead of years, every minute is precious. I don't want to wait for the doctor to drive in to the hospital. And I don't want to hear from a stand-in doctor who isn't familiar with my case. I have questions, and I need to compress both 1) acclimating to this new reality and 2) enjoying what remains of my life into a painfully short period.
Email is insufficiently interactive, but Skype is fine. I have family for emotional support, let me spend as much time as possible with them instead of waiting for test results.
It's possible/likely that better technology will make this kind of remote interaction much more palatable and useful. But it's obvious that that better technology is not quite here, and yet the hospital seems to have OKed it, as if they were doing internal beta testing an experimental feature.
I find it comical actually, in a grotesque way. It's a situation I would expect in the Simpsons: family huddled around a very ill relative, when the door opens and a tragic robot vaguely reminiscent of a Dyson vacuum cleaner rolls in and announces that the patient is going to die in short order.
The entire scene could be more bizarre only if upon this announcement, a small tray popped open with a tranquilizer pill that expedites the demise of the suffering person and prints a receipt for the "care" rendered.
I also liked that the machine must have run on sunshine and gumdrops and cost $0 to use because of course that is how health care works, we definitely have the means to heal every person on the planet, the only thing preventing us from doing so is evil white people.
If you can't, I'll do you one better - worldwide, infant diarrhoea is the second leading cause of death in children under five years old. It can be treated with pennies worth of clean water, sugar, and salt. It can be prevented just by providing access to clean water. We absolutely have the resources to heal every child on the planet of this disease, if we cared.
Hepatitis C is curable, but it is purposefully priced out of reach for much of the affected population, hoping that the local government will pick up the tab. Epi Pens have skyrocketed in price over the past few years, and the manufacturer that makes them has claimed that there is a shortage of the generic version, while plentiful supplies of the on brand version.
This is Late Stage Capitalism.
Gilead did pay $11 billion to acquire Pharmasset and at one point was facing a $2.5 billion patent infringement ruling (later overturned) for that same drug.
AbbVie’s a new entrant which can treat certain strains at at about a third the cost.
Damn that Late Stage Capitalism developing a miracle cure for Hep C which is painless and effective.
Companies making tens of billions a year while poor people suffer and die does seem to be a fairly negative situation, however you care to label it.
There are absurdly massive inefficiencies if as you say they aren't making profits.
What if the doctor couldn't get back to the hospital in time and this was the only way to tell them?
If it's over Skype or nothing. I choose Skype.
"But it should not be used to replace the empathic, emotional aspects of healthcare"
I've been to hospitals different parts of the world and this is pretty much the norm (low empathy). Most Doctors are very busy/overloaded with patients, they don't have any time to sugar-coat results or make you feel better.
This is one aspect of government-run healthcare that I'm not sure many people are willing to accept.
Well, that's not what's happened in this particular instance, nor will it be anywhere near the common case.
And if the doctor actually can't be there, then at least have the attending nurse break the news. As long as it's a warm body with good bedside manner.
We're big, squishy monkeys hardcoded to have contact with each other. We're particularly bad at making connections with people through a low-quality screen. It actually makes a difference when the person is there and present with you.
Maybe he or she can, umm... send someone else?
Enough people on this thread disagree with you that I think it's safe to say that there is no "right" method, just one that most (but not all) prefer. What's wrong with actually giving people a choice?
"Would you like critical medical news delivered to you
[x] Through teleconference (faster) [ ] In-person (depends on doctor's availability)"
Honesty is better than empathy as a job.
Subject: You're dying. Message: 2-3 weeks. Cancer. Please see attached invoice.
Some people would prefer a theater of acting sad, holding your hand and pretending to be an old friend in a strange environment, other would prefer to receive the hit at their home and cry in private. Each people is different.
"First, do no harm."
Physicians, at least in Western medicine, are bound to the principle of non-maleficence. Their obligation is to take the approach (by action or inaction) that does the least harm to most people, NOT what helps the most people. This is an important, but subtle distinction.
This principle prevents, e.g. administration of a treatment that would cure 51 of 100 patients of a chronic but not debilitating condition while killing the other 49.
It's hard to imagine the quantifiable positive ill of telling someone something in person that they'd rather receive in email. But the underlying principle here is not in helping as many as possible but, overall, hurting as few.
After begin attacked by an enraged patient (or their relatives) I can understand how the physician could develop a phobia to put him/herself in a similar situation again. Just being forced to return to the same workplace day after day can be emotionally draining and very difficult for the physician.
The biggest problem of using e-mail in this case is keeping the privacy of the patient.
This was just them pulling a stupid, and the hospital apologizing for it.
Not only is email not able to be kept private, you also can't guarantee the patient is going to get it in any sort of timely manner, or in fact, at all. It's also ensuring that no follow up questions can be asked in a timely manner.
It'd be prime material for a Tom Lehrer song involving lawyers, malpractice law, ISPs, IT professionals, email protocols, and similar related ilk. Just this simple "proposal" is blowing my mind.
The news was going to hurt one way or another, but they appreciated that other humans empathized with their situation, taking a completely less efficient means of giving them the information directly.
Granted, it's different than hearing you have a terminal disease, but both are jaw-dropping, numbing realizations few people could be mentally prepared for, especially with the swelling of emotions.
Perhaps there is no 'right' way, but IMO there is a humane way.
@polly "bad news by email?" "hell no" "just post it on twitter"
The world has changed. People are tried and sent to prison over video chat, surgeons remotely control surgery.
Telemedicine improves the quality of life for millions of people, allowing them access that they wouldn't have had in the past. It provides decreased morbidity and mortality as a whole.
Quick reminder: everyone is dying. everyone.
As are we all.
I truly do not understand why people want doctors to be required to hold hands and make eye contact, when telling there's no cure. I'd prefer doctors to be chosen based on their ability to cure illness, instead of the ability to demonstrate empathy to thousands of patients that will die during their career.
And i wonder how many of the people who are outraged by lack of the empathy from a doctor, also think that extending human lifespan to several centuries is a bad thing
https://99percentinvisible.org/episode/breaking-bad-news/
> That’s why many medical schools now offer training for students on how to break bad news, bringing in actors to help them learn how to navigate this critically important and very high-stakes moment. And that’s not the only connection between acting and this particular facet of medicine.
> It turns out that one of the first doctors to recognize the challenges of this particular kind of doctor-patient communication wasn’t just a physician — he was also a comedian. And he drew on that experience to transform the way that doctors break bad news.
> His name was Dr. Rob Buckman, and his very unusual life experiences prepared him to tackle what might be the hardest part of a very hard job. Radio reporter and part-time medical school videographer John Fecile went back to trace the strange journey of this comedic doctor, and discovered unexpected connections along the way.
I don't think "through a video screen with poor audio quality" came up, but I'm guessing Buckman wouldn't have recommended it.
Later in the week I was with someone who knew she was gonna die soon. I was talking to her and was trying to be with her. It was very difficult and I could feel part of myself slipping elsewhere. I was messed up the rest of the day. My preceptor had come into the room and left quickly, he didn't want to go there.
Anyway it does go both ways. Hospital staff need to do things to protect themselves so they can keep functioning. Ideally someone needs to be empathetic but they are also human. I don't feel delivering this sort of news via a video screen is appropriate though.
Something I heard years ago, and have never heard mentioned since, is that doctors are trained to do that, to talk shit about their patients in private, to give them emotional distance. If they let themselves care deeply about every suffering, dying person, they'd crack under the stress.
But this man and his family are flesh and blood people. And the doctor too. They have feelings. They have mental health and spiritual health needs. In the rush to deploy the technology, the human dimension was ignored.
So this might have been just another fleck of clickbait if it weren't for the fact that it's another example of a deep problem we technologists have. When we create the tool, we are also responsible for its ethical use and the impact, positive or negative, it has on the world. Don't dissociate from the impact of your work. Own it.
Not to mention that I have no wish to put another human being through the tough experience of breaking the news. Why would I want to cause them distress? It's gonna be a bad enough day as it is.
It might be a favor to both doctors and patients to have patients register their preferences in this event in advance; as we register our preferences re organ donation in many jurisdictions; or perhaps better allow people to register a preference.
I sometimes wonder if the patient demand for "bedside manner" has led to having doctors with less actual medical skill. I mean, I wouldn't choose my mechanic based on how comforting they could be. I wouldn't even choose my veterinarian on that criteria. One could argue that doctors are all roughly equal in diagnosis and prescription I suppose, making bedside manner the only real differentiation, but my personal experience is that that isn't true.
Maybe a different person should be handling the role of interacting with the patient in these ways, Someone who can take the time to do it properly? I don't know. I just think it is worth reconsidering how this works in today's world.
I would want my vet (and so far HAVE had my vets) be even more compassionate than my own doctor. I know enough to talk at least basic jargon with my PCP and specialists as needed.
None of my animals has been able to communicate about their trouble, and have relied on that extra bit of comfort and care when they are terminal, or even just very ill.
Again, personal preference.
I grew up in an auto-shop in the SF Bay, my family still owns one of them. You may not choose a mechanic based on their empathy, but the large majority (~90%) of people do. Trust is a thing that is hard to establish, but incredibly easy to break. One bad part, one snippy phone call, will totally ruin the relationship that you've built up over decades with a customer and their family. They'll never walk in the door again.
We've experimented with all forms of customer communication. From texts, to online booking, to Groupon and Yelp. Nothing works anywhere near as good as an inperson chat. When you've got to deliver the message that their car needs a $3k new transmission, despite the family road-trip in a week's time, it's best to do it face to face. Most of the time, that's not realistic, so a phone call is the next best thing. When the estimate is high like that, then it usually takes over 10 minutes per call. There's a lot of yelling and crying, usually.
People get very attached to their cars. Hell, they'll abandon their house and home before they abandon their cars[0]. When you do extensive surgery on the car they drove their new wife home in, that they drove their first-born in, that they cried in when their Mom died, that they spilled innumerable sodas in, well, you can understand why they throw money into the repairs even when it makes no sense.
Providing that 'deft hand', those years of knowledge and experience, has helped the business not just survive the Dot-Com and Housing crashes, but has let us thrive despite those economic catastrophes. Knowing how to tell someone that the car is no longer worth the repair does take some experience and care. Customers have come to trust us in helping them make decisions they have a hard time with. The majority of what trust is made of, what it can be partitioned out into, is empathy.
[0] one reason I'm not bullish on self driving car services that are all rentals and leases.
https://www.nytimes.com/2016/09/04/opinion/sunday/how-to-tel...
> You are here for her. She is his mother.
Does it really make sense that the person whose job is operating on physical trauma victims is also the person who deals with emotional trauma victims? Seems to me that those are two entirely different skill sets, and even mindsets.
On a human level, yes I'd want to hear the news from the surgeon who operated on my loved one. But on a practical level, I think I'd rather my loved one be operated on by the surgical equivalent of House than by someone less talented at surgery but with a greater capacity for empathy.
For some time, many xrays have had their initial reading done by a radiologist overseas. Tele-doctors bedside via a robot screen is just a continuation of this.
It's a pity the journalist didn't follow up by asking Kaiser where the specialist was physically located.
Furthermore, the family themselves said they didn't realize what was going on until afterwards. Which strongly suggests the doctor, for whatever reason, decided at no point to tell them, "I'm a specialist at Kaiser's radiological department in Boston...", if that were actually the case.
You CANNOT have bugs in your ventilators, pill dispensers, heart-rate monitors, etc. As such, they are typically only certified on some old version of Windows. As such, they can't be updated, or they have to re-cert that new version of windows. By certification, it goes anywhere from the bugs in the compiler all the way to the EMI interference from a cell-phone that may interact and cause a fault. It can be very intense. Re-doing a cert is an incredible mess. So, they stay on the old version and that makes integrating with all the various versions of mainframes, windows, DOS, UNIX, etc. a total disaster of a task.
I don't know how low-income people are supposed to be able to afford this. I've never even used my plan, except for flu shots and dental checkups, but I'm involved in dangerous work and play so I can't exactly cancel.
I assume Kaiser today is just a generic big company run by bean-counters. This doesn't surprise me in the least.
In a perfect scenario as it is on television a scholarly physician sits on the bedside, pats the patient’s knee and looks them in the eye and says, “we’ve done all we could”.
I worked in health care for decades, while not in a care role, I went through and managed some of the training programs to improve bedside manner/customer service. I had to document each physician as they spoke with my family member. Because of two of the three experiences they were eager to turn over the bed instead of providing compassionate care
But it really doesn't matter what we think about the robot. It matters what that family thought, and they had a problem with it. To say it's okay is to ignore their voice, because in their specific case, they weren't okay with it. It seems cold and lacking in compassion to not allow even such a simple request for the sake of comfort for someone in such a difficult place.
Really? You really are of the opinion that news about death is just "a few bits of information?" And you are capable of describing the ways humans attempt to be empathic with each other as "these theatrics?"
I'm not sure I want to live in this world. :(
Of course, we can do the be positive, be optimistic, you can fight it, you can do it mantra, and then watch as their heart breaks when they get the diagnosis. Empathy shouldn't mean helping people to delay facing the hard problems and truths.
This is the same world that largely considers suicide a crime, and denies a dignified and conscious end of life to a lot of suffering people. I watched as a family member went through the stages of physiological and mental decline, dementia, muscle atrophy, and eventually even breathing was a full time job, and it became too much. And it was a relatively painless end. (And there were others with different, faster ends. Recently one with cancer.) And taking it for what it is seemed the healthier mindset and approach.
Accepting the inevitable led to those last days and months better spent. And preparing for it is just as important.
We already drag doctors into enough futile quarrels of our own. At least that's my opinion.
I don't want to drag doctors into "futile quarrels." I just think that the occasion of death is special, and deserves to be communicated face to face, not with robots (oh sorry, with iRobots).
So you think we should systematically bring this poor experience to everyone via robots because some human doctors perform the same task poorly?
The blame is on the full device, not just the screen.
Same here. The doctor and hospital should strive to be as human and empathetic as possible given the bad news. Adding an electronic intermediary created distance and adds coldness and the artifice of bureaucracy to the event.
Welcome to 2019, everybody!
Won't somebody _please_ think of the robots!
It's not a rational thing. Of course it changes nothing, apart from the fact they might feel better having the doctor there instead of receiving it through a crappy matte screen with tinny speakers. If you still can't understand that, perhaps you can't empathize with most people.
Well, when you are ready to clock out at a certain age, people should celebrate the life you lived and make peace with the fact that this is part of life. Now a 15 year old boy /girl is very different for obvious reasons.
If his life was measured in minutes ("might not make it home") maybe they had no other choice by Skype? Maybe another doctor at the hospital but he isn't his doctor
You keep using that word, "appropriate". I do not think it means what you think it means.
should a personality qualifier be required for certain jobs?
Really poor idea, though.
We had a store in downtown Palo Alto that was a novelty for people visiting. A lot of people were weirded out by the robots at first. Usually they understood a lot better once they drove one around and could understand what they "saw".
Most of our customers were regular remote workers and they loved them because they felt like people respected them more than just being a disembodied voice on a speakerphone. Interactions were much more natural and you could use body language to a certain extent. We had several remote workers ourselves and I felt like I could communicate almost as well as if they were there, and found myself giving the robots 'personal space' like I would a person.
So I personally wouldn't be offended as long as I felt like the doctor was doing everything they could. In fact I'd much rather deal directly with the doctor so I could pick up on if they had misunderstood something about the case history, rather than to play a game of telephone with a human proxy instead and potentially be left wondering what exactly the doctor had said.
So I don't know why the doctor wasn't there that day, but I do understand that he has his own life and other patients to get to. If he's sick, or his kids were sick, or something else came up, I understand that just because he's a doctor who makes life or death decisions doesn't free him from the responsibility of the rest of his life. He may be dealing with a dozen other delicate cases that can't easily be handed off, and it just so happens that mine is the one he can't solve. Pulling another doctor in means that doctor is interrupting that other doctor. He does the triage and sends the nurse in with the robot instead.
I suspect Kaiser will revise their policy based on the publicity this has gotten. But while it might show more empathy to have someone else deliver the news in-person, I'm not convinced that it will overall result in better patient outcomes.
(I'm also assuming that since it was Fremont, CA, it's not like the robot was the only way to have a relevant specialist there. If it was a second- or third-world country, by all means send in the robot with a pulmonary oncologist to tell me there's no hope rather than having a GP try to make the call).
I used to live in Romania where hospitals are full of deadly bacteria, doctors are corrupt, nurses are corrupt. There's a shortage of equipment, vaccines, cancer treatment, important medicine, you name it. There is no place in the country to treat a seriously burned man, they all die. Obviously, lifespan here is shorter than in the US by about 4-5 years.
I suspect it isn't.
You didn't tell us how human are all those corrupt nurses and doctors? Maybe they offer first-rate compassion and spiritual support, once they pocketed their bribe?
People die everywhere, and even in poor countries people not always die because of shortages of equipment and treatments... hope in Romania terminal patients are accompanied to death with all due compassion -- this has no material costs that only 1st world can afford.