The Talk

I’ve given ‘the Talk’ more times than I can count. I’ve gotten quite good at it, and I’m very comfortable doing it. But whenever I have the chance to see someone else give the talk, I listen in to pick up things that I can use, or else see things that I would not use. On my last ICU rotation, I had the chance to sit in on a few talks, given by a variety of services.

One thing that I realized very quickly is that everyone has a bias when they give the talk. My bias is in favor of palliative care and hospice services. To me, a 5% chance of survival is a death sentence, but to a lot of people, that’s more than a fighting chance. We all take something different into the room with us when we talk to family.

Watching other attendings give the talk, there were a lot of things I wouldn’t do. None of this stuff is wrong per se, it’s just stuff that I wouldn’t do. My goal is to simplify a complicated situation. One of my attendings complimented me by saying, “You’ve got a remarkable ability to boil a complicated situation down into bite sized portions without losing sight of the person.” That was high praise in my book.

And so what I try to do is to make something complicated and fraught with emotional turmoil into something easy to digest. That doesn’t mean it’s palatable, but it can be grasped and understood.

I saw was one doc who tried to connect emotionally with the family. It was all hands-on and happy to meet you. He shook hands and hugged and patted shoulders and referred to everyone affectionately: mom and dad this, bro and sis that. He asked everyone their own opinion and encouraged everyone to talk.

The next day, the patient worsened, and I asked the family to meet again for an update, and they asked not to meet with that attending again. They saw through him like a window. They knew his concern wasn't genuine. Not that he was trying to be malicious or fake, but if you're going to play the sympathy card, you have to actually sympathize. This is why empathy is much more powerful. After you have practiced for a while, empathy is much easier. As a reminder: sympathy = I feel sorry for you. Empathy = I can see why you'd be sad. Sympathy is emotion. Empathy is thinking.

Another doc was very in tune with palliative care and hospice, but the way he presented it made it so unpalatable. He was a former collegiate athlete, so everything was a sports metaphor. It was all 'we're not going to win,' and 'do you want to throw in the towel?' Well, NO ONE wants to lose. It's like what Herm Edwards (the former NY Jets head coach) said: "You play to win the game. Hello? You play to win the game. You don't play it to just play it."

It's not fair to equate palliative care with losing, because truthfully, it's not. Palliative care is all about changing what it means to win. It's recognizing that winning isn't always about living long, but also about living well. And that choice isn't quitting and it isn't losing and it isn't giving up. A family shouldn't feel guilty for making a choice like this.

A lot of docs recommend being 'in touch' with the family, crying with them, holding hands and dabbing at tears, mourning with the family, blah blah blah. This is a mistake. It has its role, for sure, but when you are treating a patient, families are looking for authority. Like when you meet a police detective, you want him to say, "Hey, we're going to do our best to catch this guy. You let me worry about it." You don't want him to say, "I can feel your pain. Let's have a good cry, and you can tell me some stories about how he liked to fish." You want your doctor to be confident.

And it's not all about confidence in prognosis, but confident is about attitude. I may not know how things will turn out, but I am prepared for the outcome. I want families to go home at night thinking, "Well, I don't know how this will turn out, but my loved one is in good hands. I can sleep tonight and worry tomorrow."