How Do You Communicate a Disappointing Outcome?

Neil S Prose MD, Professor of Pediatrics and Dermatology, Duke University Medical Center
Michael Haglund, MD, PhD, Professor of Surgery at Duke University Medical Center

Intro text: In this scene, Dr. Haglund (playing Dr. Anderson) demonstrates the wrong way to communicate a disappointing outcome to a patient or family member.

Dr. Anderson: Hi, Mrs. Jones. It’s Dr. Anderson again.

Mrs. Jones, wife of patient [frustrated]: Hi. Is he okay? Because I’ve been waiting here for six hours, and I haven’t heard anything. Is he okay?

Dr. Anderson: They’re supposed to call you every hour, and let you know how things are going.

Mrs. Jones: I haven’t heard a thing. How is he doing?

Dr. Anderson: Well, surgery’s over.

Mrs. Jones: Okay.

Dr. Anderson: And I have some, uhh … everything went well as far as we got most of the tumor out, but it looks like he’s going to have some damage to those nerves like we talked about. He’ll probably need a tracheostomy and a feeding tube.

Mrs. Jones: What’s a tracheostomy?

Dr. Anderson: That’s the thing I told you about that you can get for a breathing tube.

Mrs. Jones: No, tell me. What’s that?

Dr. Anderson [in a patronizing tone]: I told you about that last night, when we were doing the informed consent. We talked about the risk of the surgery.

Mrs. Jones: Yeah, but there was a lot of stuff going on last night, and I don’t remember you saying he was going to have a … what is it?

Dr. Anderson: It’s called a tracheostomy, and it’s a breathing tube in his throat.

Mrs. Jones: He’s got one now?

Dr. Anderson: No, but it’s likely he’s going to need one.

Mrs. Jones: Through his throat?

Dr. Anderson: He’s going to have to have that, probably. We’ll try to go along for the next couple days to see if he doesn’t need one. He’ll need to stay intubated in the ICU.

Mrs. Jones: What’s that?

Dr. Anderson: Intubated is the tube in his throat in the ICU. It’s a breathing tube to protect his airway.

Mrs. Jones: Why isn’t he breathing?

Dr. Anderson: He’s breathing. He’s breathing on his own. The surgery is basically over. They’re taking him up to the intensive care unit now.

Mrs. Jones: Is he okay?

Dr. Anderson: Well, he is stable.

Mrs. Jones: Okay, he’s breathing okay now?

Dr. Anderson: He’s breathing on his own.

Mrs. Jones: Why would he need to have this tube if he’s breathing normally?

Dr. Anderson: Because this nerve is a sensory nerve that checks the back of his airway to make sure he swallows right, so he doesn’t swallow the wrong way. And that’s going to lead to aspiration and pneumonia. He can die from that.

Mrs. Jones [increasingly frustrated]: What’s that? Can you just … I’m worried. I’ve been worrying for six hours sitting here, and I just need you to go a little more slowly.

Dr. Anderson: I realize that, and that’s not my fault they didn’t call you.

Mrs. Jones: I know. I’m not blaming you. I just need you to go a little more slowly.

Dr. Anderson [curt]: What don’t you understand? Surgery’s over.

Mrs. Jones: Okay, I got that.

Dr. Anderson: He’s probably going to have some weakness of his nerves. It’ll lead to having a tracheostomy, and probably a feeding tube to feed him.

Mrs. Jones: I just … I don’t understand. Why? He was having trouble with his face.

Dr. Anderson: The tumor is wrapped around those nerves, and we had to get the tumor off.

Mrs. Jones: But you didn’t get it off. It’s still in there.

Dr. Anderson: There’s a little tiny bit still on the nerves.

Mrs. Jones: Why?

Dr. Anderson: Because [if I’d taken it off] then they [the nerves] would’ve been permanently damaged.

Mrs. Jones: So he’s still got the tumor?

Dr. Anderson: He’s going to go to the ICU. You’ll be able to see him in about an hour.

Mrs. Jones: And he has this thing, this tube, in his mouth?

Dr. Anderson: He has the breathing tube in his mouth right now.

Mrs. Jones: And that’s going to be just temporary?

Dr. Anderson: Yeah, until we exchange it over to a tracheostomy in a few days, probably.

Mrs. Jones: How do you know, when you say “probably?”

Dr. Anderson: Well, we’ll check and see if he has sensation back there, and if he can protect his airway. But if he can’t, he’s going to need that surgery. And usually at the same time they do that surgery, they put in a feeding tube.

Mrs. Jones: Will we get to talk to someone before it happens?

Dr. Anderson: We will go over that.

Mrs. Jones: Okay, I’m just a little surprised. He has trouble with his face, but you mentioned this, maybe. But it wasn’t presented that it was likely to happen. We’ve got things going on in our family. It’s our anniversary in a week, and we are going to the Bahamas, and we are coming back for our son’s graduation.

Dr. Anderson: That’s not happening. He’s not going to be able to go on any vacation in the next week or two, for sure.

Mrs. Jones: Okay, it’s just … I just would’ve liked a little more preparation. I don’t fully understand what’s going on. I’m floored. This is temporary, all these things you’re talking about going in his neck?

Dr. Anderson: Usually, they are temporary. But we won’t know until they’re not temporary that they’re temporary.

Mrs. Jones: What does that mean?

Dr. Anderson: That means until he gets better, we have to see him get better before those things will come out.

Mrs. Jones: But they will come out?

Dr. Anderson: I don’t know for sure until we see how he does.

Mrs. Jones: When will we know?

Dr. Anderson: Over the next several weeks.

Mrs. Jones: Okay, for which? For both?

Dr. Anderson: For both, yes.

Mrs. Jones: You’re talking about surgery in a couple days. What does that mean?

Dr. Anderson: That would be putting the tube in his throat. You’d have to talk to the ENT surgeons about that. We don’t do that surgery.

Mrs. Jones: Who’s that? When will they be here?

Dr. Anderson: They’ll talk to you in a couple days when the surgery will be set up.

Mrs. Jones: But can we talk about how he’s doing before then?

Dr. Anderson: Yeah, we come by every morning at 6:30 to round. So if you’re here at 6:30, I’ll be here to talk to you.

Mrs. Jones: Is there somebody else I can talk to?

Dr. Anderson: You can talk to one of the resident physicians. They can maybe help you out.

Mrs. Jones: Can we arrange that? This maybe?

Dr. Anderson: The resident physicians are very busy also covering the emergency room and the OR.

Mrs. Jones: I feel like I don’t fully grasp what’s going on, and I want him to be here to hear that, because I don’t know if I can explain this to him.

Dr. Anderson: Well, we’ll talk to him, but you’re just going to have to start going along with this and grasping the details.

Mrs. Jones: It’s not that I don’t want to go along with you. I’m just a little overwhelmed, okay? I’m not processing what you’re describing to me.

Dr. Anderson: Well, we will have to have another conversation about it when you’re a little more calmed down then. Okay?

Mrs. Jones: Okay.

Intro text: In this scene, Dr. Haglund (playing Dr. Anderson) demonstrates a better way to communicate a disappointing outcome to a patient or family member.

Dr. Anderson: Hi, Mrs. Jones. Dr. Anderson again.

Mrs. Jones: Hi. I’m … is he okay? Because I’ve been here for about six hours, and I haven’t heard anything.

Dr. Anderson [apologetic]: I’m sorry. They’re supposed to call you every hour to let you know how things are going.

Mrs. Jones: I haven’t heard a thing, and I’m really concerned.

Dr. Anderson: First thing, he is okay. They’re going to transfer him up to the intensive care unit. You’ll be able to see him about 45 minutes.

Mrs. Jones: Okay, that’s good. And he’s okay?

Dr. Anderson [provides a warning of bad news]: Things didn’t go quite as well as we hoped.

Mrs. Jones: Oh, okay.

Dr. Anderson: Some of the tumor was wrapped around some of those nerves we talked about last night. Remember the wax on and wax off. The general risks and the specific risks. We talked about the nerve that controls his swallowing and protects his airways.

Mrs. Jones: Yeah.

Dr. Anderson: Well, that nerve looks like it was kind of stretched to get the tumor off.

Mrs. Jones: What do you mean? It got stretched in surgery?

Dr. Anderson: In trying to get the tumor off the nerve, it looked like it was pretty thinned out by the tumor. So it’s a little worse than we thought.

Mrs. Jones: Okay, so what does that mean?

Dr. Anderson: That means there’s a chance that he’ll end up needing one of those tracheostomies for the breathing tube.

Mrs. Jones: Oh, no. You mean like on a temporary basis or …

Dr. Anderson: Remember like we talked about last night. Most likely, it’ll be temporary. But we don’t know for sure until he gets better. Usually, the nerve recovers.

Mrs. Jones: The chances are he’s most likely to be okay?

Dr. Anderson: He’ll most likely be okay. Because he’ll have the breathing tube in the back of his throat, he is not going to be sensing normally, and he’s probably going to have to have that feeding tube we talked about, also.

Mrs. Jones: Inside of the stomach?

Dr. Anderson: Yes, like we talked about last night.

Mrs. Jones: That’s because he can’t swallow properly?

Dr. Anderson: We want to get him good nutrition so he can heal quicker.

Mrs. Jones: Yeah, of course. Wow, okay. That sounds concerning. What about that? Is that something that is temporary, too?

Dr. Anderson: That’s also temporary. As soon as he’s swallowing okay, we take it right out.

Mrs. Jones: How long?

Dr. Anderson: Usually a week to two weeks.

Mrs. Jones: Wow, because we thought it was going to be a week. That’s what was presented to us. We were planning on going away on vacation because it’s our anniversary. We were going to go to the Bahamas because my son’s graduating. We were going to our son’s graduation, so it sounds like that’s not going to happen.

Dr. Anderson: I apologize. He will probably be here a week in the hospital, so it’s probably unlikely to happen right now.

Mrs. Jones: So, this is all more serious than we thought. Okay. So, you’re feeling like this is something temporary and you think the chances are that he will be okay in a few weeks. What time frame?

Dr. Anderson [acknowledging her feelings]: Yes, I think a few weeks. I think we are talking in terms of weeks. I know it’s really upsetting, and it’s not what you’re hoping for, but I think that the surgery went well, and he’s awake, and he’s going to have that breathing tube in when you see him. So, don’t be shocked when you see him.

Mrs. Jones: So, he may still not have to have the tube. The tube is going to be in his throat, not through his throat?

Dr. Anderson: Not yet. I just want to prepare you in case that’s what happens over the next couple days.

Mrs. Jones: So it may not happen if things stabilize. He may be okay and not have to have that.

Dr. Anderson: Yes, he may be stabilized and may not have to have it, but having done a lot of these surgeries, we can kind of tell when we look at the nerve. We can tell if it’s going to work really well right away, or if it needs time to recover.

Mrs. Jones: You told him this? Or I should tell him this?

Dr. Anderson: No, we’ll tell him. Don’t you worry about that. We’ll tell him. And if you want to be there when we tell him, you can be there right by his side.

Mrs. Jones: Yes, I want to be with him.

Dr. Anderson: So, we’ll have you there, and we’ll come by this afternoon when he’s a little more awake, and we’ll go over that with him, exactly what’s going on.

Mrs. Jones: Okay. He’s not going to like this, so I’d like to be there with him.

Dr. Anderson: I realize this is scary for both of you guys. We are going to be there for you. We are going to walk you through it. And we’ll make sure he’s doing okay.

Mrs. Jones: And you really don’t think it’s going to be permanent?

Dr. Anderson: I don’t know yet, but we are hoping it’s not going to be.

Mrs. Jones: Okay.

Dr. Anderson: Alright? Take care. I’ll be back to talk to you in a little bit.