The vertical hour

June 11, 2007
Surgical Rounds®, June 2007, Volume 0, Issue 0

Bernard M. Jaffe, Professor of Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA

Bernard M. Jaffe, MD

Professor of Surgery

Department of Surgery

Tulane University

School of Medicine

New Orleans, LA

The Vertical Hour,

During a recent Broadway performance of David Hare's I was moved by a single pertinent line delivered by Dr. Lucas, one of the two major characters. Dr. Lucas is a slick but thoughtful, well-respected physician, who states that "if the patient doesn't die of the disease, he dies of suspense." We have heard a lot about cancer survivors in recent years, but regardless of their prognosis and their treatment's success, every patient who develops a malignancy must have considerable doubt about his or her longevity. Hence, the suspense.

There are several possible mechanisms for coordinating cancer care. Medical oncologists frequently take the lead, inviting the participation of other specialists as needed, and provide continuity. This role also can be performed by radiation oncologists and surgeons. I formed such strong bonds with my patients that they generally invited my direct managerial involvement, and I enjoyed that responsibility.

As the theatrical Dr. Lucas implied, the lead physician's major objectives are avoiding suspense and providing peace of mind. The designation is clearly patient-specific. Thus, while a general practitioner with a long-standing professional relationship with the patient and his or her family may not have the ideal oncologic expertise, critical interpersonal experience may take precedence, allowing the practitioner to assume the coordinating role. In the play, Dr. Lucas delays his return to the bedside of a dying patient to deal with some unfinished family business and later complains that he had to wait all day for her to die. Despite his supposed preeminence and long-term patient relationship, he obviously was not the appropriate role model, nor did he set an acceptable standard.

As all of you likely have recognized, dealing with cancer patients can be both rewarding and difficult. Providing a permanent cure is incredibly satisfying, while watching a patient die despite heroic efforts is extremely painful. Unfortunately, despite recent progress, we surgeons can neither predict nor alter the outcome for many patients.

the vertical hour,

In naming his play, David Hare defined the foreign correspondent phrase, as the time immediately following a battle or disaster when the most good can be done. I was struck by how well this pertained to the period shortly after an operation, in which the surgeon can set the tone for the course of the disease, provide maximal comfort, and lessen the suspense.

There is no question in my mind but that family members are entitled to know the detailed operative findings and assessment of prognosis following each procedure to resect—or fail to resect—a malignancy. I do not think this point of view is at all contentious, and virtually all of us practice total candor in the postoperative report. Regardless of how bad the news may be, the family needs the facts, presented gently but with no inappropriate sugarcoating.

As critical as it is for the family to be informed, it is equally important that they not assume either the responsibility or take the initiative to pass the information along to their loved one. As painful as it is, we professionals have to be bearers of the bad news when that is the clinical situation. My pattern has been to request that family members do their best to dry their tears and smile as the patient returns to his or her room. Patients can easily read their loved ones' facial expressions, so they need to be as upbeat as possible. As to how they should respond to the inevitable question, I suggest that they say everything went great and they will be fine. Short of an operative misadventure, this statement is accurate and somewhat reassuring, even if incomplete.

Now, I'd like to offer a brief comment about timing. I generally delay the detailed conversation with the patient for a couple of days, so that the anesthetic has cleared completely and my charge can understand and remember what has been said. These discussions are much more difficult if the patient has misunderstood the first time or forgotten. Under these circumstances, it is almost impossible to eliminate all bias and inaccuracy. Besides, I always have felt that there was an advantage to delaying this heart-to-heart conversation until the recovery is under way and the patient is looking forward to discharge.

the vertical hour

This is when really arrives. There are many ways to conduct this discussion, all of which work as long as they are exercised gently and with compassion. I personally believe that patients are entitled to absolute candor and unbridled information, even if family members urge withholding data or sugarcoating the results. I have always believed that I can deliver the news without dashing patients' hope or evoking despair, and reports by my residents support this contention. As you all know, holding tough conversations with patients is an art, and each of us has had to learn to do it effectively. I recognize that some of you may disagree and believe in providing truthful but incomplete information to your patients. It is possible that you are correct, but I have become convinced that patients know the situation even before we inform them and, as Dr. Lucas said, "if the patient doesn't die of the disease, he dies of suspense."

and

the vertical hour.

I am certain that I do not need to remind any of you that we surgeons care for body soul. Incomplete resections and inadequate emotional support are equally severe omissions. After doing our best work in the operating room, we need to do our best work at the bedside and demonstrate that we are responsive and compassionate. The latter truly is