"Am I going to die?" "Probably not, but I wouldn't bet my life on it."
June 30, 2017 12:31 PM Subscribe
Got a new job working in the ER as an RN, been there about 6 months. Lots to learn, going great but one thing that I'm struggling with is answering tough questions patients ask. The biggie being "am I going to die?" I usually have a good bedside manner so it's annoying that I can't get this right.
I'm no stranger to death, I come from a hospice background but this is way different. In hospice it's a given that they will die, so no one asks.
In the ER it's easier when the patient has something really minor. I just say, "We are going to take really good care of you" or something.
But when the situation is bleaker I just don't know what to say. Like when the doc delivers bad news to the patient and after they leave the patient sometimes start crying and then asks "am I going to die?". I'm sometimes shadowing another nurse and they will just say "I don't know" which just seems a little mean! It's unfortunate to find out this bad news in the ER, and the nurses I work with are smart cookies but for the most part aren't the hand-holding type and I'm wondering if I could be a little less harsh.
I really like our docs but haven't been around to hear how they would answer.
I asked my preceptor and she basically said "say anything except NO." Yesterday I had a patient who was pretty upset after getting a relatively mild diagnosis and was sobbing and asking me if she was going to die. It was SO HARD to not reassure her that she was NOT going to die, but saying "we are doing everything we can" sounds so bleak.
Help?
I'm no stranger to death, I come from a hospice background but this is way different. In hospice it's a given that they will die, so no one asks.
In the ER it's easier when the patient has something really minor. I just say, "We are going to take really good care of you" or something.
But when the situation is bleaker I just don't know what to say. Like when the doc delivers bad news to the patient and after they leave the patient sometimes start crying and then asks "am I going to die?". I'm sometimes shadowing another nurse and they will just say "I don't know" which just seems a little mean! It's unfortunate to find out this bad news in the ER, and the nurses I work with are smart cookies but for the most part aren't the hand-holding type and I'm wondering if I could be a little less harsh.
I really like our docs but haven't been around to hear how they would answer.
I asked my preceptor and she basically said "say anything except NO." Yesterday I had a patient who was pretty upset after getting a relatively mild diagnosis and was sobbing and asking me if she was going to die. It was SO HARD to not reassure her that she was NOT going to die, but saying "we are doing everything we can" sounds so bleak.
Help?
"Eventually."
Then talk about the things you know for sure, e.g., treatment plan, etc.
posted by she's not there at 12:44 PM on June 30, 2017
Then talk about the things you know for sure, e.g., treatment plan, etc.
posted by she's not there at 12:44 PM on June 30, 2017
Best answer: Strangely enough, there's a Ted talk that focuses on exactly this...
posted by randomkeystrike at 12:45 PM on June 30, 2017 [16 favorites]
posted by randomkeystrike at 12:45 PM on June 30, 2017 [16 favorites]
As a patient, what I'd want to hear in this situation would be "well, as much as I'd like to be, we're not yet in the business of guarantees in medicine. But, your strep throat/ugly looking scrape/intracranial void is something that patients usually don't even remember 5 years later."
posted by The Notorious B.F.G. at 12:50 PM on June 30, 2017 [34 favorites]
posted by The Notorious B.F.G. at 12:50 PM on June 30, 2017 [34 favorites]
Best answer: Can you give people like the woman with the relatively mild diagnosis a bit of context? For example, tell her that it's a problem/diagnosis that most people recover from? Part of the scary thing as a patient is getting lots of new information and not having the background to understand if that new information means it's really serious or if it means you'll probably be ok.
You could also go talk to the people on the nursing subreddit here. I'm not a nurse but I read that subreddit regularly and it's pretty big and active, so you could probably get some good ideas from them too.
posted by colfax at 12:50 PM on June 30, 2017 [15 favorites]
You could also go talk to the people on the nursing subreddit here. I'm not a nurse but I read that subreddit regularly and it's pretty big and active, so you could probably get some good ideas from them too.
posted by colfax at 12:50 PM on June 30, 2017 [15 favorites]
Best answer: This is a short thread from the Allnuses forums on this exact topic. The answer that is most useful on what NOT to say is the last one: "I know this is an old post but I wanted to add, years ago when I was in a MVA, I woke up in the ER to find a nurse over me and I asked her "Am I going to die?". Her response..."We dont know yet." and with that walked away. Pls dont ever tell a patient this. If your on the receiving end of that...it is extremely unsettling."
posted by hurdy gurdy girl at 12:51 PM on June 30, 2017 [10 favorites]
posted by hurdy gurdy girl at 12:51 PM on June 30, 2017 [10 favorites]
Because you're inherently in the emerging-care setting, can you approach the issue as "we don't know enough yet"?
"We'll need to learn a lot more about your specific case before we can say", or "There's a lot we don't know yet for you, such as ____"
posted by Dashy at 12:51 PM on June 30, 2017 [1 favorite]
"We'll need to learn a lot more about your specific case before we can say", or "There's a lot we don't know yet for you, such as ____"
posted by Dashy at 12:51 PM on June 30, 2017 [1 favorite]
(.... or not)
posted by Dashy at 12:52 PM on June 30, 2017 [16 favorites]
posted by Dashy at 12:52 PM on June 30, 2017 [16 favorites]
My husband asked this question one time after a colonoscopy. He was doped up, but blurted out, "Am I going to die?" and the doctor said, "Yes you are someday, but not right now."
posted by chocolatetiara at 1:04 PM on June 30, 2017 [4 favorites]
posted by chocolatetiara at 1:04 PM on June 30, 2017 [4 favorites]
Best answer: What I would want to hear in that situation is "Of course not. You're going to be fine." I wouldn't come back to haunt you if it turned out you were wrong.
posted by Etrigan at 1:04 PM on June 30, 2017 [50 favorites]
posted by Etrigan at 1:04 PM on June 30, 2017 [50 favorites]
Dashy, I think in the answer I quoted it wasn't that the nurse had told her "I don't know yet," it was more that she walked away after saying it, and that was the end of the interaction. Adding more info, like in your suggestion, would probably be less unsettling.
posted by hurdy gurdy girl at 1:06 PM on June 30, 2017 [1 favorite]
posted by hurdy gurdy girl at 1:06 PM on June 30, 2017 [1 favorite]
Best answer: were ALL going to die, someday
Eventually
Yes you are someday
Just to add a counterpoint here: I would absolutely hate to hear anything like this. I'm an adult, I'm perfectly aware of the fact that humans, myself included, are mortal. You know they're asking "Am I going to die soon?" and not asking you to reflect on the shared mortality of mankind. Don't minimize their very real fear in this way.
I would like to hear something like, "I really hope not. We're going to do everything we can for you, and Dr. [So-and-So] is spectacular. You're in very good hands."
posted by schroedingersgirl at 1:14 PM on June 30, 2017 [104 favorites]
Eventually
Yes you are someday
Just to add a counterpoint here: I would absolutely hate to hear anything like this. I'm an adult, I'm perfectly aware of the fact that humans, myself included, are mortal. You know they're asking "Am I going to die soon?" and not asking you to reflect on the shared mortality of mankind. Don't minimize their very real fear in this way.
I would like to hear something like, "I really hope not. We're going to do everything we can for you, and Dr. [So-and-So] is spectacular. You're in very good hands."
posted by schroedingersgirl at 1:14 PM on June 30, 2017 [104 favorites]
I agree that I would just want a firm "No, you're going to be ok." I would be super freaked out to be reminded of my mortality while in the hospital. And who wants to die terrified?
But if you can't fudge, how about something like, "You let me worry about that. You just concentrate on getting well." Maybe follow up by asking them if they need anything to get them thinking about something new?
posted by Mouse Army at 1:16 PM on June 30, 2017 [12 favorites]
But if you can't fudge, how about something like, "You let me worry about that. You just concentrate on getting well." Maybe follow up by asking them if they need anything to get them thinking about something new?
posted by Mouse Army at 1:16 PM on June 30, 2017 [12 favorites]
Best answer: God, just be kind and say "nope, we got this."
Optimism HELPS people. So just go with it. Do some good. I promise if they do die, your inaccuracy isn't going to be what's worrying them.
(and for the love of God don't be snotty and holier-than-thou with the lectures about everyone dying someday. You know they're not there for information about whether humans are mortal. They're worried about themselves, right then, and you have the power to terrify or encourage them. Answer should be obvious.)
posted by fingersandtoes at 1:17 PM on June 30, 2017 [44 favorites]
Optimism HELPS people. So just go with it. Do some good. I promise if they do die, your inaccuracy isn't going to be what's worrying them.
(and for the love of God don't be snotty and holier-than-thou with the lectures about everyone dying someday. You know they're not there for information about whether humans are mortal. They're worried about themselves, right then, and you have the power to terrify or encourage them. Answer should be obvious.)
posted by fingersandtoes at 1:17 PM on June 30, 2017 [44 favorites]
Best answer: This is tough because different people have different emotional needs around medical information.
Some want to hear bad news as bluntly and crudely as possible so they know you aren't sugar-coating anything. Some want the sugar-coating because it makes them feel respected and cared-for. Some have an overactive imagination and go into a tailspin if they hear about unlikely scenarios. Some admire thoroughness and find it reassuring to hear your whole train of thought and all the rare thisses and thats you're ruling out along the way.
I don't know if there's any way to present this information that will be actively good for everyone. What you can do is avoid giving it in a way that's catastrophically, life-ruiningly bad for anyone. "I don't know" is unlikely to ruin anyone's life -- even the worst-case reaction is "patient crying a bunch and then eventually getting more information and feeling whatever way they're going to feel" and not, say, "patient refusing lifesaving treatment because the nurse casually said they'd be fine and they're the sort of person who jumps headfirst into denial at the slightest opportunity."
I'm not a nurse. (I used to be an EMT, but that was a lot different — we could always just say "We'll be there soon, let's see what the doctor says.") But it's possible that the coworkers who strike you as being heartless are doing it because they find it minimizes catastrophic miscommunication, and because they'd rather solidly and confidently avoid catastrophe than make a futile effort at pleasing everyone.
posted by nebulawindphone at 1:37 PM on June 30, 2017 [15 favorites]
Some want to hear bad news as bluntly and crudely as possible so they know you aren't sugar-coating anything. Some want the sugar-coating because it makes them feel respected and cared-for. Some have an overactive imagination and go into a tailspin if they hear about unlikely scenarios. Some admire thoroughness and find it reassuring to hear your whole train of thought and all the rare thisses and thats you're ruling out along the way.
I don't know if there's any way to present this information that will be actively good for everyone. What you can do is avoid giving it in a way that's catastrophically, life-ruiningly bad for anyone. "I don't know" is unlikely to ruin anyone's life -- even the worst-case reaction is "patient crying a bunch and then eventually getting more information and feeling whatever way they're going to feel" and not, say, "patient refusing lifesaving treatment because the nurse casually said they'd be fine and they're the sort of person who jumps headfirst into denial at the slightest opportunity."
I'm not a nurse. (I used to be an EMT, but that was a lot different — we could always just say "We'll be there soon, let's see what the doctor says.") But it's possible that the coworkers who strike you as being heartless are doing it because they find it minimizes catastrophic miscommunication, and because they'd rather solidly and confidently avoid catastrophe than make a futile effort at pleasing everyone.
posted by nebulawindphone at 1:37 PM on June 30, 2017 [15 favorites]
Best answer: (On preview: just read nebulawindphone's reply above over again. It says the same things but puts them more clearly :)
False hope is the worst. I'm with your people who say "anything BUT 'no'".
But really, as we can see from the varying answers above, there are different kinds of patients. Some calm reassuring want platitudes and some what will abso-fucking-lutely not trust you if you appear to guarantee something that they know damn well you can't.
I recently asked an intensive care doctor something and she replied roughly like "Well I think so but we can't make guarantees on anything in medicine." And I said "yeah I know, if you offered me certainty I'd probably think you were either dumb or lying :)"
But plenty of people are not like me, and they do want to hear gentle nothings. Since you only get a short time with these patients, it will be hard to suss out which they are. That's why your preceptor wants you to err on the side of professional medical person and not on the side of comforting encourager. It's nice when nurses can be comforting but that's not really what their job is, you know?
posted by SaltySalticid at 1:39 PM on June 30, 2017 [2 favorites]
False hope is the worst. I'm with your people who say "anything BUT 'no'".
But really, as we can see from the varying answers above, there are different kinds of patients. Some calm reassuring want platitudes and some what will abso-fucking-lutely not trust you if you appear to guarantee something that they know damn well you can't.
I recently asked an intensive care doctor something and she replied roughly like "Well I think so but we can't make guarantees on anything in medicine." And I said "yeah I know, if you offered me certainty I'd probably think you were either dumb or lying :)"
But plenty of people are not like me, and they do want to hear gentle nothings. Since you only get a short time with these patients, it will be hard to suss out which they are. That's why your preceptor wants you to err on the side of professional medical person and not on the side of comforting encourager. It's nice when nurses can be comforting but that's not really what their job is, you know?
posted by SaltySalticid at 1:39 PM on June 30, 2017 [2 favorites]
I think the answer would be different if you were an oncologist sitting behind a desk having The Talk. There people are looking to you for expertise in evaluating the probability of death. But you're an ER nurse. Anyone in the ER is likely freaked the fuck out and just looking for reassurance. i would want to be told "Not today."
posted by HotToddy at 1:47 PM on June 30, 2017 [1 favorite]
posted by HotToddy at 1:47 PM on June 30, 2017 [1 favorite]
Best answer: It's pretty unusual to get an actual terminal diagnosis in the ED. Patients either die there, get admitted for further work up/treatment, or get discharged for outpatient work up/treatment. In all those cases except the first (and patients who die in the ED are rarely going to have an opportunity to calmly ask you about it), the best and most accurate response really is that we don't know all the information yet and we're going to take care of them. Anything else is going to be either a lie or only really well suited to a specific personality type (e.g. stuff like "someday").
posted by telegraph at 1:52 PM on June 30, 2017 [2 favorites]
posted by telegraph at 1:52 PM on June 30, 2017 [2 favorites]
I was just in the ER because I randomly fainted and while I didn't think I was going to die I was way more concerned about what had happened than any of the staff I encountered. They did a good job of saying "people faint for a variety of reasons and in most cases it's xyz but we want to check you out for abc." You don't have to respond directly to the question. Just offer calm reassurance that you're doing what needs to be done and that let them know what's happening to them.
posted by TheLateGreatAbrahamLincoln at 1:55 PM on June 30, 2017 [2 favorites]
posted by TheLateGreatAbrahamLincoln at 1:55 PM on June 30, 2017 [2 favorites]
Best answer: I think some people are underestimating how vulnerable being a patient in the ER can make a person feel.
I'm a pretty tough cookie after a decade-plus of chronic and acute illnesses and when I have regular doctor visits I'm full of well thought out questions and willing to push back if I think the doc isn't listening or doesn't want to run a test I need or whatever. But if I'm in the ER with a temp of 105 and it looks like pneumonia and the last time I had pneumonia I almost died I want to hear "We're going to take very good care of you" early and often. And you can bet I want my nurses to be comforting because that actually is part of their job and I am incredibly grateful to the ones who make a particular effort.
tl;dr: "We're going to take very good care of you" plus actually taking very good care of me worked when I told an ER nurse that I'd almost died the last time I had what I was currently in the ER for.
posted by camyram at 1:56 PM on June 30, 2017 [12 favorites]
I'm a pretty tough cookie after a decade-plus of chronic and acute illnesses and when I have regular doctor visits I'm full of well thought out questions and willing to push back if I think the doc isn't listening or doesn't want to run a test I need or whatever. But if I'm in the ER with a temp of 105 and it looks like pneumonia and the last time I had pneumonia I almost died I want to hear "We're going to take very good care of you" early and often. And you can bet I want my nurses to be comforting because that actually is part of their job and I am incredibly grateful to the ones who make a particular effort.
tl;dr: "We're going to take very good care of you" plus actually taking very good care of me worked when I told an ER nurse that I'd almost died the last time I had what I was currently in the ER for.
posted by camyram at 1:56 PM on June 30, 2017 [12 favorites]
Best answer: Oh man these are such good answers, and the variability here is really helping to tease out my issue. Everyone has different needs/wants/comforts in moments of terror and vulnerability.
posted by pintapicasso at 2:03 PM on June 30, 2017 [6 favorites]
posted by pintapicasso at 2:03 PM on June 30, 2017 [6 favorites]
Best answer: How's "Not if we can help it." ?
Complies with your preceptor's requirement. Is not a lie, no matter what the situation is. Conveys to them that you're going to do everything you can. Conveys to them that there is hope. Gives you a lead-in to changing the subject to what's going to happen next or what you need them to do.
The exception would be the situations described in the TED talk linked above, which is when you absolutely know they are going to die. In that case, follow that guy's advice.
posted by beagle at 2:05 PM on June 30, 2017 [23 favorites]
Complies with your preceptor's requirement. Is not a lie, no matter what the situation is. Conveys to them that you're going to do everything you can. Conveys to them that there is hope. Gives you a lead-in to changing the subject to what's going to happen next or what you need them to do.
The exception would be the situations described in the TED talk linked above, which is when you absolutely know they are going to die. In that case, follow that guy's advice.
posted by beagle at 2:05 PM on June 30, 2017 [23 favorites]
Best answer: I was in the ER for severe dizziness following a head injury a few days prior. The doctor ordered an MRI and before I had it, he offhandedly mentions that there could be bleeding in the brain in which case I'd have to be airlifted to the next nearest big city, and I could die en route.
THANKS A LOT, ASSHOLE.
There was no benefit to having that information since there was nothing I could do with it except become terrified and inconsolable. Since I'm typing this, it obviously it turned out alright and the dizziness was chalked up to BPPV. But what I would have liked him to have said was "I'm ordering the MRI to rule out brain bleeding* and if that's occurred we will take it very seriously, but one step at a time."
tl;dr "We're doing everything we can, let's take this one step at a time."
*I know there's a term for this but I can't remember.
posted by AFABulous at 2:06 PM on June 30, 2017 [14 favorites]
THANKS A LOT, ASSHOLE.
There was no benefit to having that information since there was nothing I could do with it except become terrified and inconsolable. Since I'm typing this, it obviously it turned out alright and the dizziness was chalked up to BPPV. But what I would have liked him to have said was "I'm ordering the MRI to rule out brain bleeding* and if that's occurred we will take it very seriously, but one step at a time."
tl;dr "We're doing everything we can, let's take this one step at a time."
*I know there's a term for this but I can't remember.
posted by AFABulous at 2:06 PM on June 30, 2017 [14 favorites]
Response by poster: Oops - I understand completely that people want to be told, "No, you're going to be fine" - it's my natural impulse too. But I need patients to trust me, and guaranteeing something that is not guarantee-able undermines my profession and our brief but important relationship. AND I'm haunted of someone getting up on the floor and their pneumonia worsening and their family wailing "but the damn ER nurse said she was going to be fineeeee!!!"
posted by pintapicasso at 2:09 PM on June 30, 2017 [8 favorites]
posted by pintapicasso at 2:09 PM on June 30, 2017 [8 favorites]
Best answer: I was freaking out in the ambulance / ER (with what I *think* was ultimately just a panic attack) and what the EMR did to reassure me was say things like "Your heart looks good. Your blood pressure is good." So maybe just give a positive non-answer about what's going well?
posted by kitcat at 2:11 PM on June 30, 2017 [16 favorites]
posted by kitcat at 2:11 PM on June 30, 2017 [16 favorites]
I vote for a confident smile, "Not if we can help it", followed by a redirect with some kind of reassuring information. Or, if you sense that a patient just needs to freak out for a minute, being there to listen can help too.
I would be really freaked if I asked you if I was going to die and you [appeared to] ignore the question. Being in the ER with something that raises that particular question is terrifying, and some of the things you hear there send ice through your veins. For example, "This baby is too sick to be on the floor. We're sending her up to intensive care." Now my heart is pounding in my ears, I can barely breathe, and I need to hear loud and clear that you're going to figure out what she needs, and make it happen. The ICU nurses can walk me through the various ominous possibilities later.
posted by telepanda at 2:21 PM on June 30, 2017 [2 favorites]
I would be really freaked if I asked you if I was going to die and you [appeared to] ignore the question. Being in the ER with something that raises that particular question is terrifying, and some of the things you hear there send ice through your veins. For example, "This baby is too sick to be on the floor. We're sending her up to intensive care." Now my heart is pounding in my ears, I can barely breathe, and I need to hear loud and clear that you're going to figure out what she needs, and make it happen. The ICU nurses can walk me through the various ominous possibilities later.
posted by telepanda at 2:21 PM on June 30, 2017 [2 favorites]
I had a medical emergency a few months ago. ( My interior c-section incision came undone and I didn't know until my guts fell out in a restaurant 9 days postpartum. ) I didn't really think I was dying, I felt ok considering. Then a nurse said, "Don't worry we won't let you die. Its one of those things that would haunt us forever. Can I hold your hand?" Then I thought I might die.
posted by stormygrey at 2:42 PM on June 30, 2017 [4 favorites]
posted by stormygrey at 2:42 PM on June 30, 2017 [4 favorites]
i am left wondering: is there a legal restriction to keep an RN from saying 'yes' or 'no'? it seems like that would be 'diagnosis'. i have only ever been an EMT, and our training was too refrain from either, but be engaging and handy with the facts (e.g. blood pressure is in normal range, we don't see any bleeding...).
posted by j_curiouser at 3:15 PM on June 30, 2017
posted by j_curiouser at 3:15 PM on June 30, 2017
Best answer: In a patient you are describing (with a mild diagnosis so far), I'd probably say:
"I know it must be scary for you to not be sure about what happens next. In medicine, we really don't like making absolute predictions but I am pretty reassured by the fact that your vital signs are stable, and your symptoms are under control. Is there anything I could do right now to make you more comfortable?"
To a patient with a grave prognosis, I sometimes say things like "I know this is very stressful for you. Right now we are concentrating on [getting your blood pressure under control/ stopping the bleeding/ treating the infection] and we are doing our best to get this situation under control. I am glad the [X symptom] improved and let's hope [Y symptom] improves as well. Can I [give you some pain medication/ oxygen/ adjust your bed]?
In any situation I like to provide at least some positive information, even if small ("I'm glad your blood gases improved on supplemental oxygen/ I'm glad that we now have the X-ray results/I'm glad we were able to get a detailed history from your family member").
Not sure if that would be appropriate in the US but I also sometimes touch or squeeze the patient's hand if I think they might appreciate such a gesture.
posted by M. at 3:15 PM on June 30, 2017 [20 favorites]
"I know it must be scary for you to not be sure about what happens next. In medicine, we really don't like making absolute predictions but I am pretty reassured by the fact that your vital signs are stable, and your symptoms are under control. Is there anything I could do right now to make you more comfortable?"
To a patient with a grave prognosis, I sometimes say things like "I know this is very stressful for you. Right now we are concentrating on [getting your blood pressure under control/ stopping the bleeding/ treating the infection] and we are doing our best to get this situation under control. I am glad the [X symptom] improved and let's hope [Y symptom] improves as well. Can I [give you some pain medication/ oxygen/ adjust your bed]?
In any situation I like to provide at least some positive information, even if small ("I'm glad your blood gases improved on supplemental oxygen/ I'm glad that we now have the X-ray results/I'm glad we were able to get a detailed history from your family member").
Not sure if that would be appropriate in the US but I also sometimes touch or squeeze the patient's hand if I think they might appreciate such a gesture.
posted by M. at 3:15 PM on June 30, 2017 [20 favorites]
I would want to hear 'No, you are in good hands. We're taking care of this.' I'd just want someone to be comforting and tell me not to worry about, so the panic didn't add to my worry. I'm a grown up, I understand in a complicated emergency there is a frenzy of activity and people have roles and procedures and do what is necessary.
I had to go for an ultrasound on my gallbladder recently and the junior tech who did it stopped breathing and sighed for a moment--it was horrible, because the whole time I was thinking 'It's pancreatic cancer, isn't it???' but it turned out there was nothing and she was probably just regretting whatever she ate for lunch. People don't realize how sensitive patients are to these little pauses, exhalations, sighs, especially if you have a medical history where that brings doom (I've had a bunch of miscarriages punctuated by cheery absenteeism of techs and I would describe myself in a state of 'high alert'.)
The senior tech who showed up to check her work was forthcoming and was like 'look, we're not allowed to talk about results but let me just say this: don't spend your weekend worrying about this', meaning 'all clear'. I asked him a few hypothetical questions so he wasn't in the position of diagnosing.
Anyway: obfuscate and be confidently comforting. Few people are going to ask follow up questions: all they want you to do is say 'we are taking care of this' and I think to a large degree they are more than happy to let the conversation stop there.
posted by A Terrible Llama at 3:25 PM on June 30, 2017 [2 favorites]
I had to go for an ultrasound on my gallbladder recently and the junior tech who did it stopped breathing and sighed for a moment--it was horrible, because the whole time I was thinking 'It's pancreatic cancer, isn't it???' but it turned out there was nothing and she was probably just regretting whatever she ate for lunch. People don't realize how sensitive patients are to these little pauses, exhalations, sighs, especially if you have a medical history where that brings doom (I've had a bunch of miscarriages punctuated by cheery absenteeism of techs and I would describe myself in a state of 'high alert'.)
The senior tech who showed up to check her work was forthcoming and was like 'look, we're not allowed to talk about results but let me just say this: don't spend your weekend worrying about this', meaning 'all clear'. I asked him a few hypothetical questions so he wasn't in the position of diagnosing.
Anyway: obfuscate and be confidently comforting. Few people are going to ask follow up questions: all they want you to do is say 'we are taking care of this' and I think to a large degree they are more than happy to let the conversation stop there.
posted by A Terrible Llama at 3:25 PM on June 30, 2017 [2 favorites]
I do think this is variable. I also think what people theorize they might want may be different than reality if it happens.
It might also be different if you're the patient, but I have been through getting the news that my daughter was in a grave condition and also later that I had to decide whether to continue to fight for her life.
I also had the first neo-natal team tell me she would be okay. (She was not. Her blood gases even that early were so bad I have to think they knew that.)
For me, the truth was the only acceptable answer, but not necessarily starkly focused around death. When my daughter was transferred to her top-notch NICU team the first thing the doctor said to me was "I'm sorry to tell you your daughter's condition is grave." I needed to know. I believe I would also want to know as a patient so perhaps something like "you're in good hands. Your condition right now is X"
posted by warriorqueen at 3:34 PM on June 30, 2017 [2 favorites]
It might also be different if you're the patient, but I have been through getting the news that my daughter was in a grave condition and also later that I had to decide whether to continue to fight for her life.
I also had the first neo-natal team tell me she would be okay. (She was not. Her blood gases even that early were so bad I have to think they knew that.)
For me, the truth was the only acceptable answer, but not necessarily starkly focused around death. When my daughter was transferred to her top-notch NICU team the first thing the doctor said to me was "I'm sorry to tell you your daughter's condition is grave." I needed to know. I believe I would also want to know as a patient so perhaps something like "you're in good hands. Your condition right now is X"
posted by warriorqueen at 3:34 PM on June 30, 2017 [2 favorites]
Best answer: Especially since it sounds like it's policy at your workplace not to say "No" (and you have good reasons for not saying that as well), I would not go that route. Maybe something like "That's above my pay grade, but I can tell you that you're in really good hands with Dr. Jones." If you know it's a very very minor situation and the person is just freaking out, you could perhaps say something like "Well, I'm not allowed to make diagnoses, but I can tell you I've never had a patient die from an ingrown toenail yet..."
Another thing I would suggest, apart from the specific words you say, is that sometimes a gentle presence and someone expressing they care can be more valuable/what people really need more so than you saying the exact right words. I was in the ER and then moved up to the main hospital a couple of years ago for a thing that at the time could have been an extremely scary/deadly diagnosis, but as it turned out was very minor (yay). I will never forget the hospital assistant (not sure his exact job) who wheeled me to X-ray -- I had gotten to a point of being beyond freaked out and just started sobbing. I actually don't even think he knew my potential diagnosis -- the only time I saw him was to wheel patients from room to room -- so obviously he could not have reassured me one way or another on that count. But, he was super calm, stopped and held my hand, said something along the lines of "We're going to take really good care of you," etc. -- I don't remember his exact words, but it was more the fact that he was really calm and obviously cared that made me feel better about the situation.
posted by rainbowbrite at 3:41 PM on June 30, 2017 [5 favorites]
Another thing I would suggest, apart from the specific words you say, is that sometimes a gentle presence and someone expressing they care can be more valuable/what people really need more so than you saying the exact right words. I was in the ER and then moved up to the main hospital a couple of years ago for a thing that at the time could have been an extremely scary/deadly diagnosis, but as it turned out was very minor (yay). I will never forget the hospital assistant (not sure his exact job) who wheeled me to X-ray -- I had gotten to a point of being beyond freaked out and just started sobbing. I actually don't even think he knew my potential diagnosis -- the only time I saw him was to wheel patients from room to room -- so obviously he could not have reassured me one way or another on that count. But, he was super calm, stopped and held my hand, said something along the lines of "We're going to take really good care of you," etc. -- I don't remember his exact words, but it was more the fact that he was really calm and obviously cared that made me feel better about the situation.
posted by rainbowbrite at 3:41 PM on June 30, 2017 [5 favorites]
We're all different. I am a numbers guy in that I am constantly assessing the percentages of various events occurring. It is what you do as a trader. I ask my doctor for percentages all the time. Patients who have identical symptoms usually die what percent of the time is what I would ask the ER doctor or RN. I would want to know that 90% of the time I am going to die. I would probably want to hear that 10% of the people survive which is a more optimistic way of putting it, but either way I would want to know the odds.
I think that warriorqueen's daughter's doctor put it best when he told the truth, that her daughter's condition was grave. I think there are certain words that convey percentages and odds. Grave tells me that the chances are very slim. Critical would in my mind be bad, but not as bad as grave. Serious, even less than critical. Using the terminology that the hospital uses when admitting a patient might be the best answer with grave being the one that tells them they are not likely to make it without a severe victory against the odds.
I add one more thing. I think it depends on the patient's next of kin. Do they have family with them? If you say something to the patient they then say to their relative who arrives in two minutes to hold their hand and they repeat it, "Nurse said I am not going to die" and they do die, that makes it worse on the survivors.
posted by AugustWest at 3:45 PM on June 30, 2017
I think that warriorqueen's daughter's doctor put it best when he told the truth, that her daughter's condition was grave. I think there are certain words that convey percentages and odds. Grave tells me that the chances are very slim. Critical would in my mind be bad, but not as bad as grave. Serious, even less than critical. Using the terminology that the hospital uses when admitting a patient might be the best answer with grave being the one that tells them they are not likely to make it without a severe victory against the odds.
I add one more thing. I think it depends on the patient's next of kin. Do they have family with them? If you say something to the patient they then say to their relative who arrives in two minutes to hold their hand and they repeat it, "Nurse said I am not going to die" and they do die, that makes it worse on the survivors.
posted by AugustWest at 3:45 PM on June 30, 2017
Best answer: As a veteran of many, many ER trips with my mother where this was a very real question, "We're all going to die" would have, at very best, gotten a "no shit Sherlock" from me - and we were unfailingly kind to the nurses. That didn't tell us anything at all.
"I don't know" was fine - because it at least meant "maybe not not today". "I don't know, but we're doing X and Y and Z" was even better. Even "I don't know, and we don't know what to do" was okay - because they were still trying. (I wish I knew that ER doctor's name - I'd send him a thank you. He stood there at 3am and said "well, shit, we can't intubate her, that will kill here, we can't do surgery right now because putting her under will kill her" etc - and that was totally fine (terrifying, but fine), because I knew they were doing their best. And she made it, that time.)
Be kind, be gentle, be honest. And if being honest is above your pay grade, it's okay to say "look, I can't say, but you'll be talking to the doc soon" as long as you're kind.
(Incidentally, when we were finally told "look, she is going to die soon" it was in the emergency room. She'd been in and out of the hospital all spring, and the last time she was out, her urologist didn't like what he saw and sent her back to the ER. I arrived to give my dad some lunch and we sat there for awhile and then the ER doc came in and sat down and very gently looked at us, and they never sit down, and we knew. He said "I think you know the next thing I'm going to say" and I said "it's time to call hospice, right?" and what I remember most from that is 1) his utter relief that I didn't beat around the bush and 2) how very kind, very gentle, and very honest he was with us. So, there's that, for what it's worth.)
posted by joycehealy at 3:50 PM on June 30, 2017 [12 favorites]
"I don't know" was fine - because it at least meant "maybe not not today". "I don't know, but we're doing X and Y and Z" was even better. Even "I don't know, and we don't know what to do" was okay - because they were still trying. (I wish I knew that ER doctor's name - I'd send him a thank you. He stood there at 3am and said "well, shit, we can't intubate her, that will kill here, we can't do surgery right now because putting her under will kill her" etc - and that was totally fine (terrifying, but fine), because I knew they were doing their best. And she made it, that time.)
Be kind, be gentle, be honest. And if being honest is above your pay grade, it's okay to say "look, I can't say, but you'll be talking to the doc soon" as long as you're kind.
(Incidentally, when we were finally told "look, she is going to die soon" it was in the emergency room. She'd been in and out of the hospital all spring, and the last time she was out, her urologist didn't like what he saw and sent her back to the ER. I arrived to give my dad some lunch and we sat there for awhile and then the ER doc came in and sat down and very gently looked at us, and they never sit down, and we knew. He said "I think you know the next thing I'm going to say" and I said "it's time to call hospice, right?" and what I remember most from that is 1) his utter relief that I didn't beat around the bush and 2) how very kind, very gentle, and very honest he was with us. So, there's that, for what it's worth.)
posted by joycehealy at 3:50 PM on June 30, 2017 [12 favorites]
I'm particularly fond of "Not on my watch." It is both truthful (if they die, it is incredibly unlikely be in the ER proper awaiting triage) and conveys that while nothing is certain you will be fighting hard for them.
posted by corb at 4:05 PM on June 30, 2017
posted by corb at 4:05 PM on June 30, 2017
There is an enormous difference between what you say to a patient and what you say to their family. What is preparation for a family is existential terror to a patient.
posted by fingersandtoes at 4:48 PM on June 30, 2017 [5 favorites]
posted by fingersandtoes at 4:48 PM on June 30, 2017 [5 favorites]
Best answer: Saying “you’re going to be fine” may seem reassuring but in many cases is dishonest, and no health care provider wants to be dishonest.
I do like "Not if we can help it,” for the reasons that were mentioned.
In my experience, the family often asks, “He’s going to be OK, right?” looking for some reassurance, and a good answer for the nurse is to talk about what the members of the team will be doing to help their loved one.
But, ultimately, the response from the nurse is often a bit of a deflection than a direct answer. When the news is grim, it is not the nurse who should have the talk with the patient and the family. It is the doctor.
posted by yclipse at 5:02 PM on June 30, 2017 [1 favorite]
I do like "Not if we can help it,” for the reasons that were mentioned.
In my experience, the family often asks, “He’s going to be OK, right?” looking for some reassurance, and a good answer for the nurse is to talk about what the members of the team will be doing to help their loved one.
But, ultimately, the response from the nurse is often a bit of a deflection than a direct answer. When the news is grim, it is not the nurse who should have the talk with the patient and the family. It is the doctor.
posted by yclipse at 5:02 PM on June 30, 2017 [1 favorite]
I come from more of a counseling background than ER experience, but my thought is that you can do a lot to calm down their fear in your body language and your tone - move closer, make physical contact, such a touch on the arm or shoulder, if that seems appropriate, remind them that they are are not alone and that they take comfort in the fact that the people who know what they are doing will be doing what needs to be done. I think M's response above are good examples - just realize that your response includes much more than your words and it speaks to much more of them than their logical brains.
posted by metahawk at 5:33 PM on June 30, 2017 [1 favorite]
posted by metahawk at 5:33 PM on June 30, 2017 [1 favorite]
Best answer: You've got a lot of good answers but the piece I want to highlight is the need to validate the feelings behind their question before even attempting an answer to the text of the question. They may not want a direct, informative answer so much as they want and need to say "I'm scared." So I think a kind response would include a beginning statement of something like "I know this is scary and confusing." Just so that you recognize the notion that people in that situation are not nuts to be so nervous. What's happening is out of the run of ordinary life for most of us, thank heavens, and I always find it very human when someone says something like "I know you're really concerned" or "I understand how stressful it is to get sick so suddenly" or "not to have a diagnosis" or the like.
posted by Miko at 6:34 PM on June 30, 2017 [9 favorites]
posted by Miko at 6:34 PM on June 30, 2017 [9 favorites]
Best answer: One of the scarier things about doctors and nurses thinking you are going to die is that once they believe that, they stop worrying about you, and it shows. and if by any chance they have made a mistake, they will not catch it after that point, because their attention will be elsewhere. so the cliches about doing everything you can are quite meaningful if they're sincerely said -- most people have a vague idea that if nobody seems very worried about you, it either means you're ok or you're well beyond help. so a little worry alongside the professionalism is comforting. "we'll do our best" probably sounds like a content-free platitude to someone who always does do their best, but to a patient it does not go without saying.
posted by queenofbithynia at 7:23 PM on June 30, 2017 [2 favorites]
posted by queenofbithynia at 7:23 PM on June 30, 2017 [2 favorites]
I've spent a lot of time in emergency rooms and hospitals, and if I asked if I was going to die and someone gave me some platitude about how they're going to take good care of me, or, worse, that they know this is scary and confusing, I'd be pretty annoyed with them, if not downright angry. I'm not asking because I'm afraid or I need to be reassured. I'm asking because there are practical concerns to my own impending death, and if I'm going to die, I'd like to try to get at least some of them sorted before I kick it.
Tell me the truth. "This sort of condition has about a [percentage] mortality rate." If there's a particular reason to suspect that my likelihood of death is higher or lower than someone else's, add that in: "But you've got a [better/worse] chance because [reason]."
posted by mishafletch at 7:28 PM on June 30, 2017 [4 favorites]
Tell me the truth. "This sort of condition has about a [percentage] mortality rate." If there's a particular reason to suspect that my likelihood of death is higher or lower than someone else's, add that in: "But you've got a [better/worse] chance because [reason]."
posted by mishafletch at 7:28 PM on June 30, 2017 [4 favorites]
Anecdata: I had a loved one receive a fatal diagnosis while in the ER. And...much as we found it frustrating not to be given clear answers, we learned with hindsight that there were unfortunately not clear answers to give. People had diagnoses worse than his and lived. People had ones which were better, and died. He was very young to get the particular diagnosis he had, which was good because the stats on survivability all applied to old people. But he had some pre-existing conditions which skewed things too...
So the approach they took with us was two-pronged. First, it was to explain these things so we would understand why they really couldn't answer that. Second was to set us up with a hospital social worker, chaplain and so on to help us prepare for the eventual possibilities. That's really all that can be done.
posted by ficbot at 7:57 PM on June 30, 2017 [2 favorites]
So the approach they took with us was two-pronged. First, it was to explain these things so we would understand why they really couldn't answer that. Second was to set us up with a hospital social worker, chaplain and so on to help us prepare for the eventual possibilities. That's really all that can be done.
posted by ficbot at 7:57 PM on June 30, 2017 [2 favorites]
Response by poster: I can't get too technical with "x% of people in your patient demographic with y treatment had the outcome of z" because I'm not a doctor and I don't have the formal education to speak with certainty or the knowledge and understanding to wager a prediction in the monent, ie it would be inappropriate of me to speak in those terms, if that makes sense.
Really it seems like it just varies from patient to patient. Which means - it will come with experience as long as I keep teasing it out in my mind. Your answers helped, thank you very much.
posted by pintapicasso at 8:52 PM on June 30, 2017 [4 favorites]
Really it seems like it just varies from patient to patient. Which means - it will come with experience as long as I keep teasing it out in my mind. Your answers helped, thank you very much.
posted by pintapicasso at 8:52 PM on June 30, 2017 [4 favorites]
I'm a nurse who was in the ED with anaphylaxis and was scared out of my mind that I would, indeed, die. You'd better believe I scrutinized the body language and statements of every single person huddled around my gurney, including the guy at the head of the bed ready to intubate me. The thing that calmed me the most was the calm, businesslike, and ultimately kind demeanor of the professionals that cared for me. "Your hives are starting to fade", "your heart rate is moderating and your BP is better". These were profoundly reassuring communications. Eventually the number of people crowded around lessened, and I grasped that the emergency was over. Never have I been more relieved to have routine take over.
I perhaps have a little insider knowledge, but being updated with factual information was inexpressibly reassuring, and I actually wrote a note to the ED manager complimenting her staff afterward. And if I was actually in real danger of dying I still think fact-based updates would be appropriate, honest, and welcome. The unknown is very scary, and patients depend on nurses to both convey honest information and be there to help patients process and to comfort if the information is scary.
Know what? You're worrying about this. You will be fine!!
posted by citygirl at 9:15 PM on June 30, 2017 [1 favorite]
I perhaps have a little insider knowledge, but being updated with factual information was inexpressibly reassuring, and I actually wrote a note to the ED manager complimenting her staff afterward. And if I was actually in real danger of dying I still think fact-based updates would be appropriate, honest, and welcome. The unknown is very scary, and patients depend on nurses to both convey honest information and be there to help patients process and to comfort if the information is scary.
Know what? You're worrying about this. You will be fine!!
posted by citygirl at 9:15 PM on June 30, 2017 [1 favorite]
Late to this, but there is a whole (very good) book about this: How To Break Bad News: A Guide for Healthcare Professionals.
posted by Vortisaur at 10:31 PM on June 30, 2017
posted by Vortisaur at 10:31 PM on June 30, 2017
Best answer: can't help you specifically but unfortunately one of the previous posters is incorrect, a LOT of terminal Dxs are made in the ER. WAY too many for a variety of reasons, and WAY too many ppl die from long term conditions in the ER when they should have had time to make their plans for what they wanted their end to be.
(CPR on the naturally dying patients is one of THE cruellest, most violent thing a HCP will ever do to a patient and not get struck off for it.)
some great answers here, especially validating their fears! What pts want to know if you haven't written them off. Especially in the in-between moments, there are sometime very long delays in getting results back because someone was called off to do a crash call and people and their relatives get really nervous. As soon as they get into a bay in the ER they think everything will be done in sequence on their case from then on so it gets really scary when your Dr has been gone for 1 hour, they will automatically assume the worst. The fact that she's resus ing a baby right next door is not something you can share so sometimes humour is useful "I know you're scared, I promise we are doing everything to get the answers you need, and if we were really worried they'd be lots of people around this bed (I find turning this particular bugbear on it's head often works)
Often in this pts group you can have the patients own relatives be the difficult factor. Pt knows how busy her big exectutive son is and she KNOWS he's masking the impatience in chasing up her tests and demanding you do something. Sometimes that question is to help get through that tension which is why that validation part is SO important. Yes I know you're really scared right now, focusses the relatives mind on what is important. "If we were really worried I wouldn't encourage your son to go get a coffee, now would I? I can sit with you (if it is that kind of shift, sometimes the heavens align and you can actually spend 5 minutes chatting!)
posted by Wilder at 1:42 AM on July 1, 2017 [3 favorites]
(CPR on the naturally dying patients is one of THE cruellest, most violent thing a HCP will ever do to a patient and not get struck off for it.)
some great answers here, especially validating their fears! What pts want to know if you haven't written them off. Especially in the in-between moments, there are sometime very long delays in getting results back because someone was called off to do a crash call and people and their relatives get really nervous. As soon as they get into a bay in the ER they think everything will be done in sequence on their case from then on so it gets really scary when your Dr has been gone for 1 hour, they will automatically assume the worst. The fact that she's resus ing a baby right next door is not something you can share so sometimes humour is useful "I know you're scared, I promise we are doing everything to get the answers you need, and if we were really worried they'd be lots of people around this bed (I find turning this particular bugbear on it's head often works)
Often in this pts group you can have the patients own relatives be the difficult factor. Pt knows how busy her big exectutive son is and she KNOWS he's masking the impatience in chasing up her tests and demanding you do something. Sometimes that question is to help get through that tension which is why that validation part is SO important. Yes I know you're really scared right now, focusses the relatives mind on what is important. "If we were really worried I wouldn't encourage your son to go get a coffee, now would I? I can sit with you (if it is that kind of shift, sometimes the heavens align and you can actually spend 5 minutes chatting!)
posted by Wilder at 1:42 AM on July 1, 2017 [3 favorites]
I'm an urban ED social worker!
First off, all of you lovely peeps, if you are lucky enough to staff a social worker, you should utalize them!!!
For me, part of my perspective is that if patients are asking the question about death, that's a fantastic sign. It means there's enough emotional energy to worry about it, they are talking and breathing and conscious and logic thought which are all great things (whew!).
Response should be based on timing (do we know what's wrong) feelings (what's the purpose of the question) and expectation/course(what is really going to happen with patient).
So my responses can vary depending on those three factors. A cancer patient coming in shortness of breath who may have lung mets will get a completely different response than someone who is coming in with dizziness of an unknown cause.
Either way, the staff here is fantastic (because they are), everyone is going to take care of you(because they are). Do you have any other questions about your care? Ask for me at any time. Its a good sign you are talking walking breathing, have good blood pressure (if that's true, not always true)
If that conversation creates a bout of anxiety for the patient, as a social worker I may start working on some ways to reduce anxiety. I do this in a variety of ways 1)orientation to hospital 2) comfort (bed position, blanket, family contact, what's this or that, light level, apple juice whatever within doctors limits) 3)distraction talk-kids, family, hobbies 4) deep breathing 5) legit anxiety disorder I may recommend doctor perscribe during visit if there's a panic attack going on.
posted by AlexiaSky at 3:43 AM on July 1, 2017 [3 favorites]
First off, all of you lovely peeps, if you are lucky enough to staff a social worker, you should utalize them!!!
For me, part of my perspective is that if patients are asking the question about death, that's a fantastic sign. It means there's enough emotional energy to worry about it, they are talking and breathing and conscious and logic thought which are all great things (whew!).
Response should be based on timing (do we know what's wrong) feelings (what's the purpose of the question) and expectation/course(what is really going to happen with patient).
So my responses can vary depending on those three factors. A cancer patient coming in shortness of breath who may have lung mets will get a completely different response than someone who is coming in with dizziness of an unknown cause.
Either way, the staff here is fantastic (because they are), everyone is going to take care of you(because they are). Do you have any other questions about your care? Ask for me at any time. Its a good sign you are talking walking breathing, have good blood pressure (if that's true, not always true)
If that conversation creates a bout of anxiety for the patient, as a social worker I may start working on some ways to reduce anxiety. I do this in a variety of ways 1)orientation to hospital 2) comfort (bed position, blanket, family contact, what's this or that, light level, apple juice whatever within doctors limits) 3)distraction talk-kids, family, hobbies 4) deep breathing 5) legit anxiety disorder I may recommend doctor perscribe during visit if there's a panic attack going on.
posted by AlexiaSky at 3:43 AM on July 1, 2017 [3 favorites]
One comment on "they're not going to haunt you if you say they're going to be fine but they aren't"... if there's family involved who are privy to this information, there could end up being some resentment from them. I was in a situation like that, though I don't resent the doctor because I know more medical complications came up that he couldn't predict--but part of me still twinges at the fact we were told my grandmother had six months to live, which then changed to a few weeks, which actually only ended up being four days. I can see others responding even more poorly in situations where they were confidently told the person wasn't going to die. This likely doesn't happen a lot in the ER because of how quickly things happen, and it's different coming from a nurse than a doctor, but it is something to keep in mind.
posted by brook horse at 8:41 AM on July 1, 2017
posted by brook horse at 8:41 AM on July 1, 2017
It's not what you say, so much as how you say it.
If I asked that, I would take far less reassurance from a curtly given "neutral" answer (not today, we'll take care of you, etc) than from the truth, or some approximation thereof, given with kindness. I read much more from body language and mannerism than from this or that statement.
Also - and this may or may not be you, I don't know you personally so take this just as commentary - try not to come off as dismissive or downright judgemental. Too many HCPs are like this and it just makes the situation, whether deadly serious or less so, that much more unpleasant/awful/negative.
posted by Crystal Fox at 10:03 AM on July 1, 2017 [1 favorite]
If I asked that, I would take far less reassurance from a curtly given "neutral" answer (not today, we'll take care of you, etc) than from the truth, or some approximation thereof, given with kindness. I read much more from body language and mannerism than from this or that statement.
Also - and this may or may not be you, I don't know you personally so take this just as commentary - try not to come off as dismissive or downright judgemental. Too many HCPs are like this and it just makes the situation, whether deadly serious or less so, that much more unpleasant/awful/negative.
posted by Crystal Fox at 10:03 AM on July 1, 2017 [1 favorite]
As nurses, we have a professional obligation (and, I would argue, a moral one) not to lie to our patients. So don't tell anyone they're not going to die if you think they might.
posted by jesourie at 12:02 PM on July 1, 2017
posted by jesourie at 12:02 PM on July 1, 2017
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I could obviously see people in certain contexts taking that the wrong way, but its a hell of a lot truer than saying "no" and by refocusing to we all are going to die (including you, the treatment provider and person who is not in the hospital because of a current condition) might be reassuring?
posted by Exceptional_Hubris at 12:41 PM on June 30, 2017 [1 favorite]