Case Study: Who Should Have Told Her?
Ms. Thompson is a 48-year-old cigarette smoker with late-onset asthma. Her primary care provider (PCP) was managing the asthma with conventional respiratory treatments (e.g., steroids and rescue inhalers). The respiratory therapist observed changes in Ms. Thompson’s breathing pattern. When she asked the patient about these changes, the respiratory therapist uncovered Ms. Thompson was experiencing some pain when taking deep breaths. In consultation with the respiratory therapist, the PCP ordered a chest radiograph and referred Ms. Thompson to a pulmonologist, who found a mass in her lower right lung on the radiographs and confirmed the presence of a tumor with magnetic resonance imaging (MRI). The pulmonologist referred Ms. Thompson to an oncologist, who performed a biopsy and recommended treating the tumor with chemotherapy. From this point on, the lung cancer treatment was managed by the oncologist. In a follow up 6 months later, the PCP thinks the patient’s condition is worsening; the respiratory therapist’s progress notes seem to reflect the same concern. The PCP asks Ms. Thompson to see the pulmonologist. During her appointment with the pulmonologist, she finds a report in the chart from the oncologist indicating Ms. Thompson’s tumor has grown and spread to the liver. The pulmonologist asks Ms. Thompson, “What other treatment is the oncologist recommending for you next?” Ms. Thompson responds, “Why would I need another treatment? I am doing well with the chemotherapy.” The pulmonologist responds, “You are not doing well. Your cancer has spread to the liver. The chemotherapy is not working.” Ms. Thompson yelled, “Nobody told me that!” The pulmonologist thought to herself, “Someone needs to tell her she is dying.”
Discussion Questions
- Identify the communication problem(s) in this case.
- Who should be responsible for letting the patient know she is dying? What is the ethical responsibility of everyone in the team?
- What could have been done differently to improve the outcome in this case?
This case study highlights several communication breakdowns and ethical considerations:
- Communication Problems:
- Lack of communication between healthcare providers: There was a failure in transmitting critical information regarding the progression of the disease from the oncologist to the patient’s primary care team.
- Inadequate patient communication: The patient was not adequately informed about the progression of her illness and the ineffectiveness of the ongoing treatment.
- Responsibility for Communication:
- Oncologist: As the primary physician managing the cancer treatment, the oncologist holds significant responsibility for updating the patient about the progression of the disease.
- Pulmonologist and Primary Care Provider: Both specialists were involved in the patient’s care and had a duty to communicate effectively with the patient about her condition.
- Respiratory Therapist: While not primarily responsible for treatment decisions, their observation of changes in the patient’s condition could have prompted earlier communication with the primary care team.
The ethical responsibility of the entire healthcare team is to ensure transparent, honest, and empathetic communication with the patient. This includes conveying information about the diagnosis, prognosis, and treatment options.
- Improving the Outcome:
- Timely and Comprehensive Communication: Healthcare providers should ensure that critical information regarding the patient’s condition is promptly shared among the team and, most importantly, with the patient.
- Coordination and Collaboration: Establishing clear lines of communication between specialists and the primary care provider could prevent lapses in information sharing.
- Empathy and Patient-Centered Care: Communicating difficult news should be done with empathy and sensitivity. Patients should be informed gradually and supported emotionally through the process.
Regular team meetings or case conferences involving all relevant healthcare professionals could facilitate comprehensive discussions and ensure everyone is on the same page regarding the patient’s care plan.
In summary, effective communication among healthcare providers and with the patient is critical for delivering quality care and ensuring that patients are well-informed about their condition and treatment options, particularly in cases involving serious illnesses like cancer.