Isn’t There Someone to Blame?
Authors: Alan B. Astrow
Journal: Journal of Clinical Oncology (2008)

DOI: 10.1200/JCO.2007.12.6664 What practicing oncologist has not found him or herself unfairly “attacked” by a patient or the patient’s family? How ought one reply when the normal human response is to defend oneself? What kinds of emotions fuel harsh criticism of the physician who is caring for a critically ill patient? If our professional goal is reasoned decision-making and compassionate care, what kinds of insights can we fall back on when confronted with an accusatory outburst? I recently experienced a troubling encounter with the husband of a patient, a 49-year-old woman with metastatic gastrointestinal cancer, which raised many of these questions for me. The patient was first diagnosed 1 year earlier and had multinode-positive disease, for which she was treated with surgery followed by radiation and chemotherapy. Unfortunately, she suffered a recurrence with bulky intra-abdominal metastases.Shewas treatedwithcombinationchemotherapy, but nevertheless required paracenteses every other week for symptom relief. She suffered from fatigue, nausea, depression, and anxiety. My discussion with the patient and her husband that morning was time-consuming and emotionally draining. How long did she have to live? Her husband would have preferred that I not respond, but after the usual disclaimers about my inability to predict outcomes with certainty, I explained that it was very unlikely that she would be with us 1 year from then, and unless she had a dramatic response to chemotherapy, it was possible that she would live only 6 months or even considerably less. At that point, the patient’s husband asked, “How could this be? When she was originally treated, maybe something was missed?” I confess to feelings of exasperation at the husband’s question, and I was tempted to defend myself. But, in more than 20 years of practice, I’ve learned that defensive responses are seen, at best, as excuse-making and, at worst, as aloof and arrogant. On the other hand, there is the issue of self-respect. I felt as if the husband were questioning my competence as a physician. I had to say something. I had attended an American Society of Clinical Oncology doctor-patient communication workshop a few years before and I called to mind a few of the lessons. Avoid premature reassurance. Get out of the fixing mode. Try to identify the source of the feeling that is stimulating the accusation. Seek to understand, then to be understood. Empathize. “Clearly you are upset at the news I have just given you,” I tried. “It is hard to understand why a young woman should develop such an illness and why the treatments have done so little good.” Then, “perhaps you are feeling even now that potentially useful approaches are being overlooked. I am sure that everything that can be done is being done, but I will discuss your wife’s case again with an expert from another institution to see if there are any other potentially useful treatments or a clinical trial that she might be eligible for.” How successful this was, I’m not certain. It did allow me to maintain my relationship with the patient and her husband. But the encounter left me feeling uneasy. It’s understandable that patients and their family members would experience rage in the face of an untimely death, and that the medical oncologist, as the available physician representative, would be the recipient of that rage. But what I wish to draw attention to is not just the husband’s anger and grief. The husband was suggesting that his wife had not been treated correctly: “maybe something was missed.” The seeming implication was that I had overlooked a diagnostic test or treatment possibility early in his wife’s course, and that this omission was the cause of her impending death. A physician might sympathize with the husband, who was likely struggling with his own fears and guilty feelings, or sympathize with the husband’s frustration with the limited therapeutic options and his distress at the prospect of losing his wife, and yet still find the conversation trying. I suspect that most practicing oncologists can recall incidents where despite devoted service to a critically ill patient, we find ourselves accused directly or by implication of being the cause of a patient’s suffering. We can feel hurt and unsettled by the experience, and angry in return. In any one case, one might argue that there is a legitimate reason for a family’s attempt to fix blame. We do make mistakes, overlook treatment possibilities, speak insensitively, and so on. Critical reflection on our part promotes high standards and improved patient care—this is one of the purposes JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y: When the Tumor Is Not the Target VOLUME 26 NUMBER 9 MARCH 2