Hope and Uncertainty

Source: Wikimedia

by: Sei Lee

I wanted to alert folks to a wonderful “Piece of My Mind” article in JAMA (Mar 17, 2015) by a pediatrician about difficult conversations. As I was reading it, there were numerous phrases and sentences that poignantly rang true.

The manuscript revolves around the author and his wife’s experiences following a spontaneous abortion. Providers didn’t want to tell him the bad news, despite the fact that the ultrasound was strongly suggestive of bad news. Providers used strategies that sounded all too familiar to me.

“Uncertainty can be a ‘get out of jail free’ card for providers, momentarily allaying fears while punting the difficult conversation down the road.”

“Hope is a powerful tool that physicians have wielded incautiously throughout the history of medicine.”

As a palliative care provider, I’ve witnessed many clinicians use hope and uncertainty to avoid hard discussions. Instead of talking about what’s most likely (which is often bad news), they use phrases like, “Sometimes, there’s a delayed treatment effect”, not mentioning that most of the time, there isn’t. They say, “Let’s hope for the best”, without exploring what the most likely future holds for the patient and family. Providers that focus on an unlikely positive outcome while ignoring the much more likely negative outcome are obscuring the truth and potentially harming patients.

The author goes on to talk about the harm that can result in delaying these hard conversations, prolonging anxiety and suffering (the “pain of anticipation”) without changing the outcome. As a pediatrician, he was able to push the provider, who initially said, “we can’t be certain” into admitting, “…I would bet that you lost the pregnancy.” With this hard-won information, they were able to grieve (with ice cream), face the truth and move on to the next phase of their lives. This realistic assessment of the situation should be available to all patients, not just doctors who are able to push their colleagues into reluctantly admitting to it.