On demanding conversations (or the beginning of Hospice and Palliative Medicine)

With my time on the adolescent unit and interviewing folks for my podcast, I have a suite of skills that roughly translates over to the palliative consult service. The conversations are very similar in tone, depth, and length. The difference lies in intent and goal.

I find that the patients and family know why we are consulted and what we will talk about. They have anxiously considered the worst case scenarios during long nights in the ICU. They know what could happen.

But because these thoughts remain in their heads, they are unable to meaningfully extrapolate and plan. Similar to writing a to-do list to make the tasks real, versus running around from one chore to the next based off the last thought in your mind.

Many families and patients land on similar ground: if things look bad, then we probably do not want heroic measures. Dying at home or in a hospice would be greatly preferable to agonizing in the critical care unit. The major difference lies in the journey to that destination.

What are the dynamics in the family? These interpersonal relationships form the topography of the conversation.

In a family meeting earlier this week, we met with two sisters and a father. The mother lay non-responsive in the ICU bed while we met as a team in a conference room. Myself, the attending, a fellow, and the case manager. A packed room.

I noticed the dynamic between the sisters: one seemed like the planner and she often looked to the other for assurance or for confirmation, I’m still not quite sure which. The other sister, she recently gave birth and had four children total. To me, she struggled with the conversation the most. She had trouble articulating her thoughts, often stopping half-way through a sentence. The father sat mostly quiet, allowing planning-sister to speak for him.

I observed the fellow guiding the conversation around and then through the subject of code status. We discussed meaningful recovery and how the prognosis is still unsure one week after her debilitating brain bleed. Mother-sister asked, “When there is no hope left for a meaningful recovery, is that when we talk about hospice?”

That line threw a shiver up my back and jumped my heart rate. In that sentiment, I felt like there is a chance to turn a corner in her mind. Like a grappler visualizing the opening for a submission, I knew I had to say something.

I allowed the conversation to roll around a bit, to settle myself internally and to await a proper opening for my move.

I asked mother-sister about her wording and about the importance of language as a window into the soul. That a casual phrase might highlight something deeper.

“You said that there is no hope if your mother goes to hospice, I want to flip that. If your mother goes to hospice, the hope changes. Instead of no hope for a meaningful recovery, we hope that she can die well.”

Silence.

I think I shocked the fellow and attending with my intervention. Afterwards, they told me that they weren’t sure how it would play out. Maybe play it more conservatively in the future, they suggest. A good recommendation.

I looked over at the mother-sister, at the planning-sister, and the father. I saw the reaction. In their skin, a flush of red. In their eyes, a well of tears. In their lips, a tremble.

Then, the release. Tears flow, breath catches, and words are lost.

Mother-sister looked over at me and thanks me. She says that she hadn’t thought in that way: the hope changes.

The conversation continued. Mother-sister opened up to the idea of hospice for mom. She begins to plan, much to the delight of planning-sister.

Father shut down, fatigue and emotion weighing him down. Planning-sister noticed, summarizing the major points of the meeting for him, and then we conclude the discussion. Hugs all around.

We will watch mom’s case and be back if needed or desired.


In retrospect, I made a risky move. High risk, high reward. I felt the likelihood of success in my bones. I need to trust that instinct.

I have honed these reflexes over dozens of interviews On Death and daily practice on the psych inpatient floors. I am getting better at psychotherapy, despite no formal training. Like a younger brother that learns to wrestle by fending off attacks from an older sibling, I know enough to be dangerous. But I don’t know all the tricks and could definitely use some tips.

The group dynamic of a family meeting discomforts me. As the medical student, I take a back seat to the conversation and interject only when the bulk of the conversation has been covered. One-on-one is definitely my zone of comfort: I can control the pace of dialogue and I have the patience to sit in silence.

Not so, during family meetings. Different communication styles have frustrated me, with two decision-makers talking over each other and holding two separate conversations with the attending and the fellow. There may be long-standing dynamics and history that inform the current situation, but you rarely get that information from a chart review.

You walk in, introduce yourself, and try to read the room. Who needs what? Who feels what? What can we reasonably accomplish in this meeting?

I have much to learn from this rotation. I look forward to the next three weeks.


Long Form Sundays

On Death Podcast

3 thoughts on “On demanding conversations (or the beginning of Hospice and Palliative Medicine)

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