One fine morning as I was going on my routine rounds, my eyes were particularly fixated on an old man. It was onco-surgery ward. A ward so infamous, so notorious for all the gloom it possesses. And among all that dejection and despair filling up the atmosphere of the room, this patient was smiling brightly. I went through each of the patient writing up their notes, plans for the day and as I reached the patient in consideration, he was still smiling. I politely asked him, “Sir, how are you feeling this fine sunny morning?” He replied cheerfully that he was feeling great and more so as he was being discharged that day. I opened up his file and saw that he was a case of oesophageal carcinoma. His oesophagus had been resected but only too late. The cancer had metastasized everywhere and he was admitted with the sole purpose of attempting to prolong his life. I asked the patient again, “Sir do you know why you have been admitted here for these past days?” The patient confidently replied he was suffering from some minor ailment that caused him sore throat and vomiting of blood and now that those symptoms had been less frequent, he had healed and was ready to return to his village. So it was only natural when I asked him who had told him about the discharge and his medical condition. Of course, it was his son. And his son on being questioned why he simply replied that he wanted to see his father happy and he couldn’t gather enough courage to break the news and deal with the breakdown it ensues. So I turned back to the patient again, smiled and immediately regretted for asking that if he had any plans after returning to his village. So unaware of the certain death that lurks him, so hopeful of the future, so full of plans and so full of optimism. I too didn’t have the courage to break his heart right away. I walked out silently with a heavy heart not knowing at that very moment what it was that I should have done.
On another instance, it was this woman in her fifties. She was being wheeled into the operation theatre for a major surgery. The patient party had already given their informed consent after being explained about the whole procedure, its risks, benefits and complications. So during the course of the conversation, the attending anesthesiologist asked her how she was feeling and if she was anxious at all. The woman promptly replied that she isn’t scared at all and she thought that all those preparation and precautions were an overkill for a small injection. She casually said the injection could have been given outside as well and they didn’t need to bed her and drag her into some special place. The anesthesiologist sprung up with rage on hearing it. The operation was delayed and the patient party and the attending surgeon were summoned and inquired about the matter. The surgeon mentioned that the patient party had requested him multiple times to let them be the ones to break the news to their patient. On other hand, the patient party replied feebly that they thought all she was going to remember was an injection of anesthesia before she passed out. In their words, they didn’t want to burden her with such grave news and they couldn’t bring them self to let her know about the dangers she is facing.
These are just two instances which I experienced personally. Most of us might have been through it ourselves too. In a country like ours where a significant portion of the population is still illiterate and yet more unaware about health and medical conditions and even a huge portion of people gullible to what others say, it can very easily be projected that the huge chunk of patients do not know what afflicts them even after a correct diagnosis has been made. Of course it is the duty of the attending physician/surgeon to make a diagnosis and explain it to the patient in an understandable language but when the patient hails from a downtrodden table of society with little or no educational background (which is fairly common in our setting) often the final and the only message that gets delivered across to him is “You are DYING”.
So after a patient comes to know he is dying, a different set of dynamics comes into play. It is a gray area really. Not black, nor white. But a plain shade of frustrating, depressing, discouraging and demoralizing gray.
How do you explain hope and define optimism to someone who has never believed once that life has been fair to them and it will ever be…
How do you lie or let the relatives lie to someone who might have important things as managing his family, properties, making his last will and testaments or fulfilling his final desire and wishes? But with all the researches published that have found out optimism in a patient certainly does prolong the life and bring about favorable outcomes in the patient, you certainly tend to think twice.
So what is it that we really should do???
To go against the wishes of the patient party who suggest you to not disclose the news or to do what is ethically right and let the patient know and decide how they want to deal with the disease. In the present context, in our setting not complying by the wishes of the patient party might invite a whole new set of problems with risk of physical, social and psychological trauma for you. But even after you reveal the despairing news to the patient they might opt to abstain from any forms of treatment to save money and not become a burden for his family. They might give up all hope on life which might adversely affect at any chance of having a better prognosis. But this issue can be very much be ameliorated by a slight change in our approach to one aspect of medicine we rather choose to ignore, “counseling”. From what has been extensively researched and from what is being practiced by our counterparts on the other face of the world, counseling itself is a major factor that determines the entire outcome of the treatment.
With suitable and effective counseling, the view of the patient towards the disease and treatment process can be exceptionally altered. It is better if you let the patients know that they are not alone suffering from the disease and share the experiences of how others coped with the situation. You could always suggest picking up yoga, meditation or any other means to calm the mind. How they should utilize the time they have tying up any loose knots. And if needs be how you are always there to support him with any palliative care they may need. With a proper counseling, the compliance and adherence of patient to treatment increases, optimism in patients rise to new heights and the overall prognosis and outcomes have favorably fluctuated.
The disease the patients are suffering from is a truth, its prognosis/outcome also a truth, right to information of a human being and your responsibility to respect his sovereignty also a truth and what I firmly believe is only the revelation of this truth and a competent counseling and treatment course will be in the best interests of the patient and the treating physician/surgeon himself. And only then can we rise from the ranks of common people and truly be what the people expect us to be…
“An ethically and morally impeccable human being”.