Today was opening day of the 2013 NFL season. Thousands of NFL players and NFL fans geared up to watch the Dallas Cowboys play the NY Giants. Today, I sent a Redskins fan into the game of his life.
I met John in the emergency department. He was a healthy looking middle-aged man, dressed in a Redskins jacket and blue jeans. His chief complaint seemed rather benign. He experienced rectal bleeding for about a week, which he attributed to hemorrhoids. After further questioning, he did recall having some nagging abdominal pain, but stated it was probably gas or constipation. Come to think of it, he had been having some trouble defecating, but that could be related to hemorrhoids too, right? I continued the physical exam, only finding exactly what he told me -- blood in his rectum.
Per protocol, I started the regular workup for a gastrointestinal bleed. I ordered a CT scan to rule out possible perforations. The ER physician pulled me aside. Her eyes were suspicious. "I have a bad feeling about this one", she whispered.
I read the CT report. His stomach, liver, spleen, kidneys, even his pancreas were unremarkable. The colon, however, was not. I sensed the dread in the radiologist's voice as he dictated the remainder of the report. "Suspicious mass, possible adenocarcinoma. Recommend further testing."
John didn't have cancer. He was a healthy man. He ran 5 miles each morning through the Virginia hills. He ate a "balanced" diet, except for a few Sunday beers and pepperoni rolls while watching the football games. There had to be another explanation. Had he been constipated? Perhaps he had an obstructed bowel. Or maybe he had appendicitis. Or an inflamed bowel. Did he drink from any country streams? His symptoms may be caused by a bacterial infection. Could he have had intercourse with men? Perhaps he inserted a foreign instrument into his rectum? I was desperate. The answers to all of these questions were negative.
We scheduled John to undergo a colonoscopy to biopsy this "suspicious mass". I talked with him briefly before the procedure. We joked about the cleaning out process involving a bottomless container of GoLytely liquid. He was prepared, but visibly worried. We sedated him, and completed the colonoscopy, snagging a suspicious piece of tissue along the way. A preliminary examination of the biopsy was significant for adenocarcinoma.
The Society for Translational Oncology recommended the SPIKES method for delivering bad news, especially that of malignancy.
- Set up the environment. Ensure privacy, involve family members. Limit interruptions, and connect with the patient. Ask "are you comfortable?", "are there any other family members or friends you would like to be here?"
- Perception. Find out what the patient's understanding is of the medical condition, testing, and possible diagnosis.
- Invitation to choose the method of disclosure. "How would you like me to give the information about your test results?"
- Knowledge. Give a shot in the dark first, such as "Unfortunately, I have bad news to tell you...", then pause. Avoid being extremely blunt, especially when the prognosis is poor.
- Empathy to emotions. Observe the patient for signs of shock or sadness. Identify the emotion, and the reason for it.
- Strategy and summary. Ask if the patient and family are ready to discuss a treatment plan. Then, summarize the information given.
I stood in John's hospital room. His eyes diverted from the football game, and placed on me. His wife placed her novel on the bedside table. Should I be the one to break the news? John had only met me a day ago. And I was only the family doctor, the middleman. I was neither the radiologist who spotted this lesion, nor the surgeon who actually visualized it, nor the oncologist who would treat him. I couldn't answer his questions regarding treatment options.
I recalled my grandfather's anxiety while waiting for his own diagnosis. I recalled my own angst about his care and the way his physicians broke the news and prognosis to him.
So, like a losing quarterback with time running out, I spiked.
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