Featured Commentary: Theresa Brown, RN
Theresa Brown is an oncology nurse and author of the book Critical Care: A New Nurse Faces Death, Life, and Everything in Between, available now. A frequent New York Times contributor, her essay "Physician, Heel Thyself" was recently among the paper's most e-mailed.
Pulmonary Central: Oncology and critical care are sister specialties in that (moreso than other areas of medicine) they are defined by the tension between optimism and realism, of "doing everything" without doing too much. The line of futility is usually blurry, often invisible, and we slip over it daily without knowing. What do you see as the best way of managing this tension?
Theresa Brown, RN: This is a great question, especially when you put it in terms of the overlap of oncology and critical care. In speaking with the ICU nurses who take care of our patients I often hear that they find our patients very difficult because of how compromised we have made them with chemo. To them it seems the treatment itself falls in a blurry area because they see the patients who get so terribly ill from the treatment, and at times don't survive the negative effects of the chemo.
I think the best way of managing this tension is for all members of the medical team to talk to each other, and have that conversation incorporate ethical principles about futility and patient autonomy. The oncologist can explain why the care choice was not, according to the data, futile. Nurses can then weigh in, saying we understand the rationale for the initial care decision, but it seems important to reevaluate considering how fragile the patient has become. There needs to be a reason for continuing care in the face of possible futility beyond "This is what the doctor wants" and everyone on the team needs to have input and feel heard. We also need to share the content of those conversations with the patient and the patient's family. We need to be honest with patients, and at the same time extremely compassionate.
PC: We physicians may have an even harder time than others at seeing the reality of a patient's circumstances and prognosis, especially when our sincere desire to save "our" patient intermixes with ego, professional pride, fear of failure and maybe even of death itself. Any war stories of care that went too far? What would you like to say to those attendings, or wish their inner voices would whisper more loudly?
Ms. Brown: We all have stories of care that went too far, but I will share one here. We had a patient with amyloid of the heart who received a heart transplant only because we had promised to do a stem cell transplant to cure the amyloid. The course of this patient's treatment was grisly and extremely painful for the family. Among other difficult symptoms, the patient became unable to eat, and after a couple of months died in the ICU. I do not believe the patient's best interests were served by getting either the heart transplant, or the stem cell transplant, especially since, by the time of stem cell transplant, the patient's disease (amyloid) had progressed to the point where a stem cell transplant was very unlikely to do any good. The entire situation was very troubling, and equally troubling was how the details came out in dribs and drabs, meaning we nurses didn't even always understand the complexities of the patient's care needs.
I wish these attendings would say to themselves "It's not about me." It's not about the doctor's treatment decisions, but rather what the patient wants for herself or himself, and what it is realistically possible to achieve. It is hard hard hard to tell patients with cancer that we have no effective treatment to offer them, but if an attending responds to that difficulty by selling them on a treatment that is very unlikely to have any positive effect, we have done the patient a deep disservice. Treatment choices must be made by the patient, but they absolutely must be making an informed choice.
PC: To me, nurses are in a privileged position of getting to deliver the most immediate and emotionally "real" care. But they can also be trapped in the position of directly delivering care they may find to be too much or inappropriate. How do you cope with this? How do you maintain compassion (including for yourself) if you feel you are directly causing unneeded suffering?
Ms. Brown: My first task is to find out how the patient feels about the level of care. If the patient's desires differ from the doctor's I bring that difference in opinion to the MD's attention. If I know the patient chose a risky treatment because it is her only chance of surviving, then the compassion comes easily because that patient made an informed choice. However, in cases where the docs have sugarcoated the difficulties of care, and continue to sugarcoat despite the patient's deep reservations about going on with treatment, it can be very hard for me to feel positive about my work. I continue to feel compassion for the patient, but it's hard to feel compassion for myself in that situation, because I don't feel what I'm doing has integrity. The worst part is that I start to lose faith in the whole enterprise. One patient who is suffering pointlessly, and without being forewarned, can make me feel cynical about all of oncology. That's a shame, because many people are alive and healthy today who wouldn't be without our treatments.
PC: What do you see as the sources of tension and breakdown in nurse-physician communication and our working relationship?
Ms. Brown: Nurse-doctor communication is so very vexed in the hospital. In general I would say that tensions arise because both groups are very busy, have different sets of obligations to be fulfilled, and don't always understand the pressures the other group is under. That is, stress makes poor communicators of all of us.
It's important to note that nurses receive very little, if any, training in how to work with doctors, and my understanding is that doctors receive very little training in how to work with nurses. This educational elision makes no sense to me. They need us, and we need them, and yet the very little education nurses get in dealing with doctors tends to focus on situations where the two groups are adversarial, not the multitude of situations where writing an order and then implementing it are either completely straightforward, or the result of a collegial discussion between nurse and doctor. During a graduation speech I gave in December at the Shadyside School of Nursing here in Pittsburgh I said "Doctors are your colleagues." At work I find myself saying "We all have the same goals."
In my Op-Ed "Physican Heel Thyself" I wrote about the problem of physicians who bully nurses (and other members of the healthcare team). Many commenters wrote in about nurses being bullies, which does also happen. There is a general problem with civility in the hospital, and MDs and RNs both need to strive harder to achieve civility. However, MDs who bully are a huge part of the problem since they get away with being intimidating to staff, and in the process show that bullying is acceptable in the hospital, and undermine the idea of a health care team with the patient at the center of all our endeavors.
Theresa Brown, RN regularly contributes to the New York Times "Well" blog. More of her writing is online at theresabrownrn.com.
(Posted June 1, 2011)
