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Balancing Honesty and Optimism with Critical Care Patients

Posted Jan 25 2013 12:00am

I have a high degree of respect for critical care physicians who are constantly on the spot to make key life-and-death decisions for their patients. A recent article discussed how physicians in general, and intensivists in particular, need to balance honesty and optimism in their interactions with sick patients and their families (see:  Balancing honesty and optimism in critical care ). Below is an excerpt from the note:

A recent little essay entitled “Do patients bond best with doctors who misinform them with optimism” got me thinking about balancing honesty and optimism in practicing any medical specialty in which patients not infrequently die. Tragic things can happen in the pediatric intensive care unit. Anyone who works there — doctors, nurses, respiratory therapists, and many others — see these tragic things. Children are there who are seriously ill or injured, and some of them die....When I meet someone new and they find out what I do they often ask me how I do it, often adding that they never could. More than a few of these people are physicians. My answer is that I don’t really see the question in the same way that they do. For one thing, tragic things happen whether or not I’m personally there to see them. Tragedies are a part of life, and I have the privilege of participating in that aspect of life. The experiences I and my fellow intensivists have in our work are now unusual, but once they were common — they were shared among most adults a century ago. So, in a way, what I participate in with a child and the family has been usual for far longer than it has been unusual. That’s what I mean when I say that participating in these human events is a privilege. It really is. I am an optimist. Even when the chances of a child’s good outcome are long, I can still proceed optimistically. I can even show my optimism to the child’s family. But, of course, I must also be honest with the family — if the situation is dire, I need to tell them that.

But I don’t think those two things are contradictory. I don’t think I hold out false hope, but I do tell families that I’m hopeful. This way of practicing goes against a common technique of PICU practice, one which many call “hanging crepe.” The idea is that the doctor can be hopeful and optimistic with families until the outcome begins to look increasingly ominous. At that point, to prepare families for the probability of death, the doctor becomes progressively more pessimistic with them. I think that approach underestimates the ability of families to discern for themselves that things are not going well –  nearly all do....In essence, I think most families easily adopt what is really the common sense approach humans have used for millennia in the face of critical illness: realistic about the chances, but still optimistic. The physician’s job is to tell families (and children) what we know about the chances, but there is no reason not to remain optimistic, too.

For me, one of the most insightful aspects of this essay is that tragedies such as the death of a child can be part of life and that physicians are privileged to be able to support patients and their families under such circumstances. For most of recorded history, such events took place within the home rather than in hospitals and intensive care units. In fact, ICUs may now always be the best place for deaths to occur but this is another discussion. A second key point is that physicians should strive to achieve a balance between honesty and optimism in the face of life-threatening disease. Unfortunately, intensivists may not know some of their patients well but this is one of the challenges to be addressed as we move to a much more hospital-centric healthcare system. 

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