Not Answering Is Also an Answer

DOI: 10.1200/JCO.2014.55.3495 It was a typical day in the life of a hematology/oncology fellow who thought she had mastered the art of multitasking. Hoping to save time, I went to the oncology clinic to see a new patient while nurses were getting her bed ready on the floor. I was told she had been recently diagnosed with metastatic non–small-cell lung cancer and was now presenting with worsening shortness of breath and dysphagia resulting from extrinsic compression from mediastinal lymph nodes. Accompanied by the internal medicine resident and making a mental list of the patient’s admission orders, I entered the room to find a middle-aged woman and two companions. I introduced myself and started asking the initial interview questions. She answered some of my questions but barely looked at me. After 10 minutes, she paused, looked at me, and said, “You have terrible bedside manners.” Her frustration was obvious and her rudeness deliberate. I was accustomed to receiving praise for my bedside manners, and this was the first time I had received such harsh and direct criticism. I felt the heat rise to my face; I must have looked flushed when I asked, “Tell me why?” I felt the urgent need to sit down and realized I should have been sitting when I first began speaking to her. “Do you know who these people are?” she asked, motioning to the two friends who had accompanied her. Of course, I did not, because when I had introduced myself to them I had not thought to ask their relationship to the patient. “You are telling them everything about me and you didn’t bother to check with me if it was okay.” With thoughts of potential lawsuits and embarrassment regarding my indiscretions, I apologized. But I was frustrated that she had allowed me to proceed with the questioning for 10 minutes before interrupting me. I felt as if she was testing me, or maybe I was just feeling defensive because of my initial misstep. Regardless, she was right. I asked if I could continue. “Yes, it is okay,” she answered briefly, “but next time, you should ask that before you start talking, and I am very tired now. You should really look into the patient’s chart before asking the same questions again.” To respect her wishes and seek some respite, I excused myself and exited the room. I made sure her pain was addressed and also that she was sent to the floor as soon as possible. This had not been a good start, but I left hoping that, with better pain control and more rest along with an extra amount of tactfulness on my part, our next encounter might be better. As I stepped into her room the following morning, my hopes were dashed. I found her sitting in the chair in pain and short of breath, clearly in distress. I made sure my bedside manners were the best, but she continued to avoid eye contact and answered in what I felt was a passive-aggressive tone, questioning all of my suggestions regarding her care. It was very disturbing to me to see that I was not able to establish a good relationship with her, and I was offended that, despite verbally accepting my apologies, her body language and demeanor contradicted that acceptance. She requested supporting literature for everything that was to be prescribed. I began to question my skills with regard to her management but soon became aware that she treated the entire staff in the same manner. As the days wore on, she continued rejecting everything—from pain medication to respiratory therapy. She would say, “I will read the literature about this and decide later. I know my body better than any of you. I am not stupid.” And indeed she was a very smart woman who was able to reject and deflect all the team suggestions with intelligent and well-thought-out arguments. But unfortunately, she never made any decision regarding her management, even as she became increasingly uncomfortable. We suggested palliative chest radiation and continued to urge her to make a decision, but she did not. She refused to let us contact her family or friends, telling us that she knew that we could not contact them without her permission. Every possible strategy to reach her, from extreme politeness to tough love, failed. No staff member could breach the wall she had erected. The entire team was feeling impotent in dealing with her situation. Out of sheer frustration and even though we knew the answer before we called for a consultation, we sought the opinion of psychiatry. Their opinion was that she was competent to make her decisions, but they could not elaborate further because the patient did JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 32 NUMBER 25 SEPTEMBER 1 2014