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On Unrealistic Expectations

May 14, 2015

It is often difficult to convey  to families of critically ill and injured patients what they need to expect.  The human part of me wants to reassure them that “everything will be all right.”  Yet, in this era of lawsuit bonanzas, such statements can be professional suicide.  Once you give them that reassurance, if anything less than “all right” occurs, the family will think we must have done something wrong.  Recriminations and potential litigation can easily develop from that point forward.

Consequently, I’ve moved away from providing reassurance or even encouraging hope.  I don’t actually need to give them hope; they’re going to hope for the best anyway, with or without my encouragement.  I’m going to hope, too.  If I weren’t hopeful for a successful outcome for my patient, why would I even try?

Unrealistic expectations among the public were revealed in a noteworthy article that appeared in 1996 in the New England Journal of Medicine.  The authors reviewed an entire year’s worth of medical television shows (ER, Chicago Hope, Rescue 911) looking for episodes of cardiopulmonary resuscitations.  Among their findings were that 65% of the cardiac arrests in these scripted shows occurred in children, teenagers, or young adults. Of course, this is completely backwards from the real-life experience, in which the overwhelming proportion of cardiac arrests occur in people who have sick hearts — that is, mostly older people.

More importantly, 75% of the patients survived the immediate arrest, and 67% appeared to have survived to hospital discharge — within an hour (including commercials) at that.  While the survival rates of in-hospital cardiac arrest vary by the type of clinical report in the literature, all are well under 30%, and most average no better than 5% for the more common elderly hospitalized patient who suffers an arrest.  And, of course, the usual hospitalization typically lasts for several weeks or even months, and such patients are not usually too functional when they leave the hospital.

Just as patients fail to understand the reality of their health situation, given the erroneous portrayals usually see in the media, caregivers often fail to realize the degree of ignorance patients and families have about what to expect.  Clear, patient, calm, and thorough explanations to help them understand the situation and potential outcomes is key.

We can’t keep them in the dark.  We have to explain what we know and what we’re thinking.  We may even have to be brutally honest to paint the realistic picture of the experiences we commonly see.  They are actually depending upon us to convey that knowledge and experience to them.  Sometimes it’s a paradigm shift to explain medicine in simple terms that put patients and their families in our shoes, seeing the uncertainties just as we see them.  We must help them see the situation through our eyes.

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