ER provider diagnosing cancer... And visiting patients upstairs after admit?

[Guest ERCat]

Yesterday I had a 50-year-old woman come in with a complaint of shortness of breath. She and her OB/GYN had thought it was due to heavy menstrual bleeding and resultant anemia. She came in with a hemoglobin of 6.0, but was refusing any sort of transfusion for religious reasons.

 

I did my typical shortness of breath work up which included the chest x-ray which showed a 3.5 cm mass in the right lung. I got a CT, and it showed a similar mass with surrounding scattered opacities. The radiologist impression simply was "pulmonary metastatic disease."

 

My supervising physician told me to go in there and tell the patient she had cancer. I told him I was hesitant to do that, because although it is likely cancer we cannot diagnose it without a biopsy, so I did not feel comfortable telling her that she had cancer. He thought that was a "cop out" that a lot of providers make… He said "The radiologist said it was cancer, and it looks like cancer. If you were to go in there and tell the patient she had suspicious masses on her chest CT, she would assume it was cancer. People aren't stupid. You can just tell her it's cancer and don't beat around the bush." I think he was a little frustrated with me, so he ended up going in and telling the patient that.

 

What I would have preferred to tell the patient is this: "Unfortunately your chest CT showed some concerning findings. We found a mass with some nodules surrounding it, and it's very suspicious for cancer. We need to admit you to the hospital and have you see a lung doctor in a cancer doctor to make the exact diagnosis."

 

What are your thoughts on this?

 

PS. As an aside, there have been a few patients that I have admitted that I really wanted to check up on upstairs before I start my shift in the ER. Like this woman. Just day hello and to see how they're doing. Obviously I would make sure the patient knew that I was just saying hello, that I was no longer part of their treatment team. I think it would make them feel good to have that connection. However, I have not done it because for some reason I don't think it would be very professional? Thoughts on this?

[Reality Check 2]

I like your more caring subtle approach.

 

Perhaps avoiding words like Unfortunately, Sadly might be advisable.

 

Keeping some hope by using words or phrases such as "well, I know why you might be having trouble breathing.... your chest xray and CT scan show us a mass. To find out exactly what the mass is will require a biopsy. It could be cancerous. We will get you admitted to the hospital and make sure your oxygen improves while we get a closer look at that". Not too flowery or child like.

 

Just a thought. I have tried not to start sentences or discussions with "downer" words. Yeah, it is cancer, but try to soften the blow.

 

When I was in the ER I did go upstairs sometimes to follow up on a patient. Usually, the ICU. Sometimes, the family would see me looking in and inquire who I was. When I told them I saw their loved one in the ER, they were often comforted that someone cared and thanked me for my efforts. I don't think it is out of bounds. It shows caring and concern for patient outcome and humanity. 

 

Glad you care!!!

[ventana]

people tend to know what is going on

 

I have seen several providers been proven wrong when they leaned forward on a Dx, you do not have tissue, and although the Rad thinks it looks like it I would not Dx cancer off that alone

 

Hgb 6, DOE, lung MET - who the heck knows where her CA is  - sounds like CA but who really knows 

 

So I would go in, sit down away from the door, close the door, and have a good discussion with them, heck you can read the report from the rad so allow them to hear the word "cancer" (which might well be helpful in the long run)

 

Then I would go into a talk about what we "know" -- we know there is a mass on  CT, and that her Hgb is very low

The into what we  "think" - we see anemia with CA and these findings point towards cancer

 

Then talk about what we would like to do (I call is data gathering) - Admit and work up

 

 

I would make sure to say cancer, and that it looks like it, but I would stop short of calling it this as we have no tissue and you really gain nothing by making that Dx leap except set yourself up to be wrong....  and if you are wrong it is going to be a horribly wrong Dx - 

 

 

BTW with out an Abd/Pel CT you are guessing... and even that might not help

[rpackelly]

You were right.  Someday your ED attending will develop an acute case of "foot in mouth disease" and devastate someone unnecessarily.   In oncology, "tissue is the issue".   Anything else is just a picture.  

[True Anomaly]

Your approach is the correct approach.

 

I typically approach this by using a similar "You have a large mass in your lungs that we found on the scan. There is a wide range of possibilities that it could be, and this does include cancer, but we need more information to be able to know exactly what it is"- and then kinda tailored to the patient and the situation.

[rev ronin]

Really, people?  It's cancer until proven otherwise, so tell the patient it's cancer until proven otherwise.  I see a lot of semantic hair splitting here, but it's not our job to be pussyfooting around a probably terrible diagnosis just because it's not finalized.

 

Any provider should be able to prepare himself or herself to, within 5 minutes, go into a room and tell a patient that he or she is probably dying.  If you're in an institutional setting and not comfortable doing it, get a chaplain to come talk you through how to deliver bad news.

 

I tell my patients all the time "You don't pay me to be an optimist" when I'm recommending tests or imaging to rule out unlikely things--and I mean it.  The nice thing about being a pessimist is that I'm either right... or pleasantly surprised.

 

So by all means, say "likely", "probably", "consistent with", "my clinical impression is..." and all the other weasel words, along with "hope that I'm wrong", "specialist will make the final diagnosis", "testing to be sure" and things like that, but at the end of the day someone has to tell the poor patient that she has cancer.  If you can do that, you're more valuable to your SP than if you cannot.

[Guest ERCat]

I am not afraid to give bad news. I am afraid of diagnosing something that's out of my scope. I am not an oncologist and I am not biopsying that patient, so no - I can't be certain that it is cancer. Unless I am 100 percent certain I would be taking a risk. What if the patient had some other rare disease that presented that way and I was the lady who told them they had cancer and caused them (and their families) emotional distress from misdiagnosis? Talk about a lawsuit waiting to happen. Telling the patient "You have a mass and it's probably cancer" isn't weaseling out of anything. I can't say it's cancer unless I've seen the tissue!

[ventana]

Really, people?  It's cancer until proven otherwise, so tell the patient it's cancer until proven otherwise.  I see a lot of semantic hair splitting here, but it's not our job to be pussyfooting around a probably terrible diagnosis just because it's not finalized.

 

Any provider should be able to prepare himself or herself to, within 5 minutes, go into a room and tell a patient that he or she is probably dying.  If you're in an institutional setting and not comfortable doing it, get a chaplain to come talk you through how to deliver bad news.

 

I tell my patients all the time "You don't pay me to be an optimist" when I'm recommending tests or imaging to rule out unlikely things--and I mean it.  The nice thing about being a pessimist is that I'm either right... or pleasantly surprised.

 

So by all means, say "likely", "probably", "consistent with", "my clinical impression is..." and all the other weasel words, along with "hope that I'm wrong", "specialist will make the final diagnosis", "testing to be sure" and things like that, but at the end of the day someone has to tell the poor patient that she has cancer.  If you can do that, you're more valuable to your SP than if you cannot.

 

 

Recently I have dealt with a patient that was mis-Dx just like this

only briefly - then told he had sarcoid

 

He talked VERY poorly of the people that told him it was CA and not something else - he want through HUGE grief till the correct Dx was done (via bronch Bx)

I try not to give my patients MORE suffering then they already have

 

As said earlier - I think you say the word cancer so they can start to adapt and process, but at the same time state we are not sure and that admission is really the needed next step for Bx.  I know that is how I would want to hear it.....

[delco714]

I will come back to this later. But you don't diagnose cancer without tissue. The rest is being compassionate

[db_pavnp]

Great thread.  Hoping for more.

[delco714]

On further review, the folks above hace said everything else I would have. Your head was in the right place. I urology I have conversations like this many times a week. Also, feel free to Check on a pt later on. Er docs ask me how pt's did all the time.. Never seen one check in..

[Boatswain2PA]

I don't diagnose CA in the ED.  There are too many types of cancer, and too many cancer mimics, for me to make that leap.  I'll prepare patients to hear that diagnosis by telling them my impression, and what I think, but I don't tell them what I don't KNOW.  

 

As to following up in the ICU or on the floor, or even just looking at the downstream EMR - I do it as often as I can, mostly so I can continue learning.  

[EMEDPA]

I have visited a few folks I've admitted upstairs over the years...ones I liked or really had a connection with.

[ajnelson]

I think it's important to be up front and honest with our patients. My conversations are usually somewhere along the line of...'The radiologist noted a mass in your lung on the CT scan that is concerning for cancer. This is going to need (admission) or (follow up with your doctor and xyz specialists) to come up with a definite diagnosis. I explain that I can't give them an actual diagnosis in the ED, that they need further testing that will likely include additional radiology exams, biopsy, bronch, etc

[sk732]

I think it's important to be up front and honest with our patients. My conversations are usually somewhere along the line of...'The radiologist noted a mass in your lung on the CT scan that is concerning for cancer. This is going to need (admission) or (follow up with your doctor and xyz specialists) to come up with a definite diagnosis. I explain that I can't give them an actual diagnosis in the ED, that they need further testing that will likely include additional radiology exams, biopsy, bronch, etc

 

This is my approach, one it seems I've been having to use a lot lately.  While not firmly definite, I am blunt and up front and ensure that they are aware of what the worst case scenario potentially is, so it isn't a shock.

 

SK

[RoxieDarling]

This is a random question, and I'm not sure if there is another thread addressing it, but as a PA student how likely is it that we would give such a diagnosis to a patient or family? Would a PA student ever tell a family in the ER that their loved one passed of an Aortic Aneurysm? Or tell a patient they have metastatic cancer in the ER/Clinic/any setting really? I had a discussion with a colleague earlier today about this, and I am under the impression that divulging that news as a student is not our place, but they disagreed with me. I just wanted to know the consensus on this if possible.

 

Thanks!

[rev ronin]

This is a random question, and I'm not sure if there is another thread addressing it, but as a PA student how likely is it that we would give such a diagnosis to a patient or family? Would a PA student ever tell a family in the ER that their loved one passed of an Aortic Aneurysm? Or tell a patient they have metastatic cancer in the ER/Clinic/any setting really? I had a discussion with a colleague earlier today about this, and I am under the impression that divulging that news as a student is not our place, but they disagreed with me. I just wanted to know the consensus on this if possible.

It really depends on the preceptor's assessment of the student and family's readiness to, respectively, deliver and hear that news.  In general, yes, that is something that I would rather do and have my PA student watch... but it wouldn't always be the case.

[LT_Oneal_PAC]

This is a random question, and I'm not sure if there is another thread addressing it, but as a PA student how likely is it that we would give such a diagnosis to a patient or family? Would a PA student ever tell a family in the ER that their loved one passed of an Aortic Aneurysm? Or tell a patient they have metastatic cancer in the ER/Clinic/any setting really? I had a discussion with a colleague earlier today about this, and I am under the impression that divulging that news as a student is not our place, but they disagreed with me. I just wanted to know the consensus on this if possible.

 

Thanks!

It would depend on the setting, diagnosis, prognosis, the patient, and heavily on the student. Definitely would though, after they spoke with me and told me how they would relate the information.

[Boatswain2PA]

Really, people?  It's cancer until proven otherwise, so tell the patient it's cancer until proven otherwise.  I see a lot of semantic hair splitting here, but it's not our job to be pussyfooting around a probably terrible diagnosis just because it's not finalized.

 

Any provider should be able to prepare himself or herself to, within 5 minutes, go into a room and tell a patient that he or she is probably dying.  If you're in an institutional setting and not comfortable doing it, get a chaplain to come talk you through how to deliver bad news.

 

I tell my patients all the time "You don't pay me to be an optimist" when I'm recommending tests or imaging to rule out unlikely things--and I mean it.  The nice thing about being a pessimist is that I'm either right... or pleasantly surprised.

 

So by all means, say "likely", "probably", "consistent with", "my clinical impression is..." and all the other weasel words, along with "hope that I'm wrong", "specialist will make the final diagnosis", "testing to be sure" and things like that, but at the end of the day someone has to tell the poor patient that she has cancer.  If you can do that, you're more valuable to your SP than if you cannot.

Rev - All those "weasel words" as you call them make the statement much different from what the OPs SP wanted them to say.

 

The SP wanted the OP to say "You have cancer."  That's wrong because they didn't have definitive diagnosis.

 

I concur with others..."Prepare yourself because this is likely cancer.  But it could also be other things, some of which can also be dangerous, so I'm admitting you for further testing."

[Guest JMPA]

unless diagnosed, it is reckless and potentially malpractice to tell a patient that they have cancer without a definite diagnosis. if the patient is truly diagnosed with cancer then it is ones duty to inform the patient. it can be done one on one or with a psychologist /team that can provide support. the doc in the OP statement is reckless and inhumane

[Torshi]

Could just say it's a possibility, but yea I'd be the type to never jump gun until it's objectively dx'ed w/ biopsy considering that's how we're all taught. It baffles me people can just jump to bold conclusions regardless of imaging impression. As many have mentioned, sarcoid or other mimics could be present, common? Probably not, but there's a reason medicine is based on evidence. 

 

simply explain the possibility, show some compassion, guide them towards next step, and move on.