Breaking the Collusion of Silence

Breaking the Collusion of Silence

Don S. Dizon, MD, FACP, FASCO

@drdonsdizon
May 22, 2018

Originally published in "Discussions with Don S. Dizon" on The Oncologist.

Perhaps one of the hardest things about medicine is cross-coverage, that is, to be the covering doctor for your partners, whether for the occasional night, weekend, or longer. It’s not something done only in oncology. All specialties in medicine have this system, which allows us to have lives outside of our hospitals and clinics. What’s hard about it, for me, is not the hours covered, but assuming care for patients I do not know. In such circumstances, I rely on my partner’s sign-out, their documentation covering the last outpatient visits, or when necessary, their guidance provided on a phone call. Cross-coverage has made me aware of the art in medicine, and in oncology. Nowhere is this art more significant than when it comes to patients living with advanced cancer.

Years ago I was on call over a long weekend—in addition to covering calls I also rounded on our very busy inpatient service. One such patient still stays with me. She was in her fifties, and she had metastatic lung cancer—it had spread to her bones, liver, and her brain. She had been on chemotherapy as an outpatient and had been admitted a couple of days prior to manage treatment-related toxicities. I remember walking into her room. She struggled to turn her head, but she smiled as I came in.

I remember asking how she was. “Fine,” she said. “I just need to get stronger so I can go back on treatment.” I looked at her—she was cachectic except for her protuberant abdomen. Her labs showed anemia and LFT abnormalities, reflecting the tumor that was taking over her liver. She looked like she was dying.

But I didn’t know her. I reviewed the notes by my colleague­—about the discussion over progressive disease despite her last trial of therapy. I searched for evidence that they had talked about prognosis in those notes, that he had talked about “incurability,” “terminal disease,” “death,” or any other loaded word, but I didn’t find it. Instead, he had recorded options for next steps, and that they had chosen one path.

Now she was in the hospital, with complications due to treatment. Although I do not treat lung cancer, I sensed she did not have long. But I wasn’t her doctor. Back then I believed it was not my place to initiate a discussion best left to my partner. Theirs was the doctor-patient relationship I cherished so much in my own practice, and end-of-life discussions are not something to be left to the covering doc… In the end, I said nothing. I examined her, told her I agreed with what our treatment team was doing, and then left her room. She had no questions for me, but then again, I didn’t ask her if she did.

Monday came around and I was no longer on call, but I followed this patient’s course in the hospital. Unfortunately, she did not recover and ended up passing away in that hospital bed. Even today I wonder why I didn’t say anything, and whether I should have. Was I concerned that my colleague would be mad, or that I would be undermining their relationship? Was I concerned about following the right protocol—how one is supposed to care for a colleague’s patient? Mostly I asked myself if it was to protect myself, so I wouldn’t be the bad guy giving bad news to a woman who was holding on to hope. Some would say I contributed to this “collusion of silence,” that I purposely hid my fear that she was dying from her, as others did as well. After all, hadn’t she had a right to know what I thought?

These experiences (sadly, it repeats itself often) have taught me that assuming the care of patients for our partners is not synonymous with babysitting them. We have to be clinicians, and we need to meet their needs and address their questions as professionals in our own right. This means answering their questions with our best-informed opinions, particularly when asked about prognosis. Cancer is serious and scary, and for some, it will prove terminal. When I meet patients at that point, I’ve learned to be honest, at least as honest as I can be. I’ve learned to be as comfortable saying “I think you’re dying,” as I am saying “I don’t know,” depending on what I believe to be true. Mostly, I’ve learned to walk alongside a patient, even if it’s just for a day, because, although it might be a short period, for however long it is, I am their doctor.

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