JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 7, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.0496
‘‘Seeing is Believing’’: Imaging Modalities Aid in Decision Making in End-of-Life Care Hakeem J. Shakir, MD 1,2
‘‘
A
picture is worth a thousand words.’’ This oftquoted adage captures an undeniable truth about human nature. Human beings are visual creatures and heavily influenced by what they see. Therefore, when a patient suffers a life-altering and potentially life-ending brain hemorrhage or newly diagnosed tumor, displaying the image to the decision makers, whether a computed tomographic (CT) scan or magnetic resonance image (MRI), facilitates the arrival to a conclusive decision in that particular patient’s care. Throughout the course of my second year in neurosurgical residency, I quickly came to the realization that I was a bearer of bad news and felt as if I were a ‘‘grim reaper,’’ purely based on the nature of my job. All new patients who come through the emergency department with any brain pathology are seen and evaluated by the second-year resident before any other personnel from the neurosurgery department (i.e., midlevel resident, chief resident, and attending) sees them. The patients waiting to be seen sometimes have newly diagnosed brain tumors and brain hemorrhages with oftendismal outlooks. As a junior resident, my job is to not only gather the patient information, history, and examination findings to later share with the attending neurosurgeon but also to have a frank conversation with the patient and/or family about the diagnosis, prognosis, and treatment options available. Difficulty lies significantly in conveying the reality of the situation with compassion and honesty to the patient, and more so the family, when the patient is incapacitated due to their condition. The conversations we as residents are confronted with on a daily basis involve end-of-life care, such as hospice or palliation, versus the potential for surgical intervention. We do not make decisions for patients but rather provide options that can be taken given the patient’s wishes, or more commonly, what the family wishes. In the event where the patient has delineated no explicit instructions, health care decision makers feel the burden of choosing a treatment option. What
the family or decision maker wishes for their loved one is significantly influenced by a number of things, such as personal beliefs, cultural norms, and previous conversations with the patient regarding end-of-life care. More important in the decision making process, however, are the objective data that are unmalleable and harsh appearing at times, yet sometimes the best information to expose to the decision maker. Although no empiric studies have been conducted with regard to treatment decisions based on the presence or absence of image review with patients and families, our anecdotal experiences lead us to believe that when a CT scan or MRI is reviewed in the presence of patient and family, decisions are made more expeditiously and with an overall greater understanding of the disease process. In my humble opinion, the hackneyed expression ‘‘seeing is believing’’ carries significant weight in the field of neurosurgery. The decision between clot evacuation or comfort measures for an elderly woman whose 80 + year-old husband has suffered a fall and subsequently become obtunded from an increasingly expanding brain bleed, exacerbated by his use of blood thinners, becomes much easier when the CT scan is displayed, showing the devastating compression left by the clot. Decision makers may even elect for aggressive, yet only life prolonging, measures; but even then, the visualization of an image has certainly given them a greater understanding and aided them in their ultimate decision.
Address correspondence to: Hakeem J. Shakir, MD University at Buffalo Neurosurgery 100 High Street, Suite B4 Buffalo, NY 14203 Email: [email protected]
1 Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York. 2 Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.
863
‘‘Seeing is Believing’’: Imaging Modalities Aid in Decision Making in End-of-Life Care Hakeem J. Shakir, MD 1,2
‘‘
A
picture is worth a thousand words.’’ This oftquoted adage captures an undeniable truth about human nature. Human beings are visual creatures and heavily influenced by what they see. Therefore, when a patient suffers a life-altering and potentially life-ending brain hemorrhage or newly diagnosed tumor, displaying the image to the decision makers, whether a computed tomographic (CT) scan or magnetic resonance image (MRI), facilitates the arrival to a conclusive decision in that particular patient’s care. Throughout the course of my second year in neurosurgical residency, I quickly came to the realization that I was a bearer of bad news and felt as if I were a ‘‘grim reaper,’’ purely based on the nature of my job. All new patients who come through the emergency department with any brain pathology are seen and evaluated by the second-year resident before any other personnel from the neurosurgery department (i.e., midlevel resident, chief resident, and attending) sees them. The patients waiting to be seen sometimes have newly diagnosed brain tumors and brain hemorrhages with oftendismal outlooks. As a junior resident, my job is to not only gather the patient information, history, and examination findings to later share with the attending neurosurgeon but also to have a frank conversation with the patient and/or family about the diagnosis, prognosis, and treatment options available. Difficulty lies significantly in conveying the reality of the situation with compassion and honesty to the patient, and more so the family, when the patient is incapacitated due to their condition. The conversations we as residents are confronted with on a daily basis involve end-of-life care, such as hospice or palliation, versus the potential for surgical intervention. We do not make decisions for patients but rather provide options that can be taken given the patient’s wishes, or more commonly, what the family wishes. In the event where the patient has delineated no explicit instructions, health care decision makers feel the burden of choosing a treatment option. What
the family or decision maker wishes for their loved one is significantly influenced by a number of things, such as personal beliefs, cultural norms, and previous conversations with the patient regarding end-of-life care. More important in the decision making process, however, are the objective data that are unmalleable and harsh appearing at times, yet sometimes the best information to expose to the decision maker. Although no empiric studies have been conducted with regard to treatment decisions based on the presence or absence of image review with patients and families, our anecdotal experiences lead us to believe that when a CT scan or MRI is reviewed in the presence of patient and family, decisions are made more expeditiously and with an overall greater understanding of the disease process. In my humble opinion, the hackneyed expression ‘‘seeing is believing’’ carries significant weight in the field of neurosurgery. The decision between clot evacuation or comfort measures for an elderly woman whose 80 + year-old husband has suffered a fall and subsequently become obtunded from an increasingly expanding brain bleed, exacerbated by his use of blood thinners, becomes much easier when the CT scan is displayed, showing the devastating compression left by the clot. Decision makers may even elect for aggressive, yet only life prolonging, measures; but even then, the visualization of an image has certainly given them a greater understanding and aided them in their ultimate decision.
Address correspondence to: Hakeem J. Shakir, MD University at Buffalo Neurosurgery 100 High Street, Suite B4 Buffalo, NY 14203 Email: [email protected]
1 Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York. 2 Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.
863
