Case study: what went wrong?

bellcollector · Feb 19, 2006

First of all I think it needs to be explored exactly what the MD has told her versus what the family has told her. I am a huge advocate for informed consent. Unless this women has been declared incompetent for some reason she has every right to know the details of her diagnosis and prognosis. As an advocate for this women I would explore everything and rule out a concrete reason to keep the truth from this women. If none exisists I would get social services involved and make sure she is properly informed. But that is just me.

SmilingBluEyes · Feb 19, 2006

I so agree w/bell collector. What a dilemma. This woman has the right to know the real truth, IMO.

mtnmom · Feb 19, 2006

I agree with the above posters.

did the physician chart anything in the progress notes about discussing the prognosis? if so, with whom?

Perhaps it would not be a bad idea to go ahead and alert social services.

The only other possibility I can think of is that she does know the truth and is in some serious denial.

SFCardiacRN · Feb 19, 2006

Informed consent is in the realm of medicine...not nursing. Her primary care MD needs to be informed that she has questions about her diagnosis and prognosis.

allnurses Guide · Feb 19, 2006

I also think you have to take into consideration that after hearing the word "cancer" alot of people just shut off their ability to hear anything else or they hear things wrong.

My husband encountered some bleeding problems while at the dentist and needed further workup . . .we ended up with an oncologist who told us he might have cancer. He went on to explain the tests that would come up and the timing of the tests and what they were for. When we got into the car after the appt., I started talking to my husband about the tests and he said "What tests?". He had no recollection of any conversation after the word "cancer". And he is A/O x 4 . . . . . . :clown:

I've noticed that, depending on the state of mind of the patient, people don't always hear what you say. I've talked with patients in the morning before rounds and then when the doc comes in, they are confused about what we just talked about. Or the doc will come in and talk to them and later they will ask again about what their diagnosis is.

steph

ceecel.dee, MSN, RN · Feb 19, 2006

I also think you have to take into consideration that after hearing the word "cancer" alot of people just shut off their ability to hear anything else or they hear things wrong.
steph

Agree. It's now time for a family care conference to include the doc, primary nurse, social worker, and any avialable family members. This ensures that all are on the same page.

An appointment with a grief counselor might be considered to follow-up.

ceecel.dee, MSN, RN · Feb 19, 2006

What went wrong here? Who, if anybody is to blame? How should the nurse address the situation?

Perhaps the kids think it was "protective" for Mom to hear a much scaled down version of the truth.

I too, would have to hear from the doctor what exactly was said.

There is usually plenty of "blame" to go around in these miscommunication episodes, and placing blame isn't usually helpful in solving root issues.

NephroBSN, BSN, RN · Feb 19, 2006

I'm interested in seeing what you guys think about this situation and how it should have been handled. There are actually two parts to this, but I will only post part one first.
You enter the room of KG, a pleasant, 78 y/o African-American female. When you greet her, she starts to cry. She states, "My children told me today that they found cancer on my lungs. It's just a tiny spot on the tip of my lung and they could just scrape it off but the doctors don't think I would survive the surgery. I've been sitting here all day trying to figure out why they would think that. I am in good health otherwise, I don't understand why they won't even try to save me. Is it because I'm poor or Black or is it because I'm old they don't think I care about living anymore? I can't believe they are just going to let me die without even trying to help me!"
You spend a few moments with Mrs. KG comforting her and then you return to the nurses' station so you can review her chart. You find that she has indeed been diagnosed with lung cancer, but it is a large tumor that is inoperable. It is not as Mrs. KG has been told "a tiny spot on the tip of her lung which can be scraped off".
What went wrong here? Who, if anybody is to blame? How should the nurse address the situation?

I believe, as some other posters here do, that the patient is in denial. If she heard that the tumor is tiny and yet she would die if they scraped it off, then that tells me she didn't hear correctly or is in denial.

If it truely were a tiny spot then they should be able to operate.

I believe she is in denial and bargaining stages of grief at the same time

You might want to review Elizabeth Kubler Ross and her description of coping with grief etc. Remember the stages aren't sequential . And one can regress to a lower stage at any time.

caroladybelle, BSN, RN · Feb 19, 2006

It would be nice to know what the MD actually said.

I have had many patients tell me all sorts of things that are completely contrary to what I witnessed that the MD actually did say. People frequently "hear" what they want to hear.

One of my pet peeves is the "The MD is going to cure me" after they have discussed "treating" an incurable tumor. Or the "I'm cured, they couldn't find any cancer in me" after a few tests are run and chemo done, only to have the cancer show up 4-5 years after being "cured".

Have they run other tests to check for mets...an essential part of staging for treatment?

The other thing is that if this is an isolated mass, they generally will radiate/give chemo to shrink it and help prevent many problems with symptomology, mets, extension. This is "treating it" while not curing it.

As a general rule, the only way to definitively cure lung cancer (permanently) is to remove the tumor and a large margin of clean tissue. This not something that can be "scraped" away, this is major open chest surgery. You would have to have excellent lung condition ( something most lung ca patients don't have - given the predominant risk factors), a good cardiac profile (removing a large portion of lung alters pressures on the heart significantly), and be able to rehab well, something that is a rare combination in a 78 year old. And if there is invasion of any tissue outside the lung, or near the heart this heightens risks to the patient, as all cancerous tissue must be excised. Any distant mets pretty much rules out a good chance of cure, therefore the surgery which poses major risk of killing/disabling the patient quicker than the cancer, without good chance of cure is not a good option.

I have also had 78 year olds that say that they are very healthy, but ignore the blood pressure pills, heart pills, diabetes, etc.

And the other part of the story is?

SharonH, RN · Feb 19, 2006

And now for the rest of the story......

Just as you finish reviewing the patient's chart, you look up and see one of her consultants in the doctor's charting area. He is a pulmonologist who is well-like by both nurses and patients. You explain Mrs. G's concerns about her diagnosis and he is surprised to hear it. He goes into her room to talk to her and you wait about 20 minutes to return.

As you enter the room, Mrs. G starts crying again but this time for a different reason: she is angry. She states "Dr. B. came in and told me the truth. Did you send him in here? I called my daughter and asked her why they told me that other story and she said that they were afraid I couldn't handle the full truth. I feel so embarassed; they treated me like a child! How dare they lie to me. I was thinking that these people were going to just let me die for no reason! They had no right to lie to me like that." You spend another 20 minutes comforting Mrs. G as she considers what she just learned about her health and her feelings of betrayal.

As it turns out, the children had went to the physicians and requested that all diagnoses and treatment plans go through them first and the physicians complied, somthing they had no right to do.

What went wrong is that this was a basic HIPAA violation. The patient was fully capable of participating in decisions about her own health and the physicians had no right to discuss her diagnosis with her family without her permission, something which gratefully she did not catch on to because she was so angry at her kids. This led to a scary diagnosis made even more traumatic because of deliberate miscommunication and a grown woman was made to feel silly and betrayed. It's hard to believe that they would have done this if the patient had been 48 or 58 or even 68. I wonder what the fallout would have been if a nurse had made this error?

clee1 · Feb 19, 2006

It's hard to believe that they would have done this if the patient had been 48 or 58 or even 68. I wonder what the fallout would have been if a nurse had made this error?

Can you say.... lawsuit?