Working at a teaching hospital, we are used to treating patients from all walks of life, from children to the elderly. Treating an 18-year-old young man with epigastric pain seemed simple enough.
He presented to our emergency department with intermittent stomach pain that had been occurring for about two months and was getting worse. He was also experiencing progressive fatigue and debility. The senior resident and PGY-2 admitted the pale-looking young man with a modestly low hemoglobin level and epigastric pain. There was no history of illness except for a motor vehicle accident five months prior, which required a medically induced coma while the patient underwent a compound fracture repair of his left leg. He was not a drinker or smoker, and the family history was just as innocuous.
The initial suspicion was that the patient had peptic ulcer disease, so the residents consulted gastroenterology for an endoscopy the morning of admission. During rounds, we noted that his vital signs were stable and anticipated discharging him within 24 hours of his endoscopy. After all, what can an 18-year-old without any significant medical history possibly have?
We teach our residents that although they will encounter exceptions in medicine, they should generally look for horses not zebras when they hear hoof beats. We tend to associate certain diseases with certain age groups. For example, we associate coronary artery disease with someone who is middle-aged and has some related risk factors.
But this patient was an exception. His diagnosis turned out to be esophageal adenocarcinoma poorly differentiated. We scheduled him for neo-adjuvant chemotherapy followed by surgery, and he was later found to have metastatic esophageal adenocarcinoma to the brain. Given his age, this diagnosis was not even within the realm of consideration.
What is the moral behind this young man's heartbreaking diagnosis?
Assume nothing. We often form initial opinions about a patient's case based on a single factor. In this case it was his age. This tendency can affect our decision making and approach if we aren't careful. Perhaps thinking outside the differential diagnostic box at times will allow us to consider a rare or uncharacteristic diagnosis.
Be prepared. It is difficult to communicate bad news effectively if you have not prepared for how you will handle the situation. The following tips may help:
Don't rush. Take a moment to prepare your thoughts so you can share the news in a sensitive way.
Don't allow staff members to discuss the situation where patients or family members might overhear the news before being told directly.
Make sure all stakeholders are present for the family meeting, including the patient's care team and representatives from all treating specialties who can offer support and respond to patient and family questions.
Ensure privacy, and allow ample time for providing the news and developing a plan of action.
Focus on empathy and listening, and consider the patient's and family's emotional needs and perspectives.
While nothing can change a patient's unfortunate diagnosis and prognosis, the manner in which we communicate bad news can alleviate undue emotional distress on the patient and family.