Mrs. Wright - "But The Surgeon Said..."
‘But the surgeon said he got it all...’
When we first meet her, Mrs. Wright has been diagnosed with colon cancer, and has had her initial surgery. She arrives at the oncologist's office two weeks after her surgery, unaware of the seriousness of her disease, and unaware that she will require further treatment.
"But the surgeon said he got it all..."
The patient reports that the surgeon said he 'got it all' which, of course, may or may not be what the surgeon said but it is what the patient now remembers about the interview. Patients who have been told that a procedure "got it all" often believe that they've been cured. Thus, the conversation with the patient may have to take on the character of a breaking bad news interview.
Another important aspect of this interview is the discussion and explanation of chemotherapy, which can be confusing for many people.
What to watch for
Here's another example of how you might deal with the information, expectations and implicit hopes that a patient might have. Note that in this scenario that the physician doesn't know what was said and discussed with the patient's surgeon, so he doesn't tackle that issue. Instead, he stays with the patient's feelings and uses the EVE techniques for validating, exploring and empathizing.
Mrs. Wright - "For A Time?" (Recurrence)
Mrs. Wright must be told that her latest tests reveal the presence of liver metastases, and the physician needs to explain to her what treatment options she has at this time.
"What do you mean 'for a time'?..."
This is another example of an emotionally-loaded discussion about recurrence. She asks a tough question, which expresses shock and disbelief. Many of the issues and questions have great significance for the patient and need to be addressed appropriately. The patient and physician discuss a treatment plan, but importantly they also discuss the impact of this news on the patient and her future.
What to watch for
In the initial part of the interview, the physician makes the transition from the previous visit to the current interview by explaining the reasons for the previous tests--the narrative approach. Further on in the interview the oncologist handles several difficult questions, first by exploring the concerns behind the questions and then by answering the patient with honesty and empathy. Notice that the physician's answers combine honesty with realism while couching hope in tentative terms.
Mrs. Wright - Transition To Palliative Care
The physician must inform Mr. Wright that her liver metastases have progressed, and that treatment options from this point onward would be aimed at palliation, not cure. By exploring her reaction, he is able to find--and help address--her biggest concern.
"But surely something else can be done..."
For those patients who are not cured, the transition from potentially curative therapy to symptomatic or palliative treatment is usually extremely tough on both the patient and the physician. Patients may fear abandonment at this point, and physicians may feel sad or helpless, or even as though they have failed their patients. The clinician needs to be aware of how difficult this process of transition is and can be helped by a strategy as you see here.
What to watch for
In this important end of life discussion the oncologist again uses a narrative approach, or a recap, to introduce the topic with the patient. Notice how particularly important it is in this case to obtain the patient's perception of the illness because the information to be given turns out to be quite dissonant from her own expectations. Note also how the physician allies with the patient by expressing a desire similar to hers for a positive outcome, and that he does not respond to her distress with an offer of further curative cancer treatment, but he couches future strategies in terms of a benefit to her.
Exploring the patient's emotional reaction is a very important component of SPIKES. When the patient in this scenario says 'you can't just give up.' further exploration is warranted because it is not clear what the patient really means by this phrase, in fact, probing the patient's concerns results in the physician discovering the real issue for her.
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