In an obstetrician’s career, tragic unexpected outcomes are, sadly, part of everyday practice. However, being present when a family member is affected by a tragedy, such as the loss of a pregnancy, is the reality you never want to face. In this situation, we face the blurred lines of what our role is – clinician or relative? – and the issues surrounding patient consent are made more complicated.
It is Saturday night. I am driving to a night shift when my brother calls. Something is not right. He tells me the symptoms his wife, who is 22 weeks pregnant, is having. I tell him to meet me at the hospital immediately. The drive is long. The whole time my brain assesses probabilities – my eyes water and my chest hurts. All I want is for everything to be okay. All I want is for my gut instinct to be wrong. As I enter the birthing room they both look up, silent desperation paints their faces. The midwife is trying to find a heartbeat; the silence is too hard to bear.
An ultrasound scanner sits in the corner. The private obstetrician is still 40 minutes away. They see me glance at it. The worry etched on their faces begs me to perform the scan. I do. Any hope there was is now gone.
The role of a doctor
Historically, the doctor’s role has been defined by the Hippocratic Oath. Doctors should act in the best interests of their patient, accept responsibility, develop a trusting relationship with the patient and display professional commitment. On the other hand, the role of a family member is to love and protect, be able to communicate and comfort without words, and to offer support through the good times and the bad.
When these roles become intertwined, it can be a challenging experience for us as doctors: the emotional investment in your family versus the diagnostic capabilities of your mind. The natural instinct is to jump in, find a diagnosis and cure the sick; yet when we find ourselves in a scenario like this, should we learn to take a step back and let another doctor take over that role?
Doctors have always been discouraged from providing medical care for family members, dating back to ethical principles from the early 1800s that argued for the separation of professional and personal identities in the care of family members.1 Reasons for this stem from the emotional distraction related to the patient as family member that can cloud one’s decision-making, critical thinking and sound judgment.2 The consent process itself can also be tricky; withholding details in order to protect the ones you love.
From experience, dissociating oneself from a loved one who is in a grave medical situation can be difficult. Physicians have recognised that, at times, it is not feasible to keep their personal and professional lives separate; indeed, it is morally impossible.3 One feels compelled to be involved and carry out whatever task is needed solely to care for a family member, blind to the risks at stake.
From the family member’s point of view, it can be an overwhelming relief to be treated by a familiar and loving face; a person they trust and understand.4 The attention to detail, empathy and thoughtfulness of a loved one is in stark contrast to a stranger’s care, no matter how well-qualified and professional the practitioner may be.
Finding the balance between your internal identity and responsibility versus the external influences of family and profession can be hard. Nothing can truly prepare you in your career for simultaneously being a concerned family member and a person who has a position of responsibility.5
To obtain consent is not only a mandatory legal requirement, but also a part of good medical practice for any operation, procedure or treatment administered to a patient.6 Consent can be implied in certain situations, where the patient shows their agreement through their actions or by complying with instructions.7 As doctors, however, we should take particular care when relying on implied consent, as in some cases there can be misunderstandings if construed the wrong way. In an obstetric setting, interpreting implied consent can be as simple as performing an abdominal palpation on a smiling antenatal patient; however, in the case of an adverse outcome, it can be far more complex.
When doctors face delivering news of an undesirable diagnosis, we are expected to interpret a patient’s body language and then act in response to it. We provide the sad news, the appropriate facts, tailor the quantity of information and predict the consequences the results will have. Consent is said to be valid if the patient has the capacity, the correct information and acts voluntarily, but fulfilling these requirements in a split second of momentary decision-making is far easier said than done. Furthermore, the patient’s capacity at the time to make clear decisions, especially as relayed by body language, is questionable.
Breaking bad news
Breaking bad news is a task many doctors have to perform daily, yet its importance is often undervalued.8 It requires skilful communication, the strength to be honest and the ability to remain calm while conversing.9 These traits, in addition to tailoring the amount of medical information given to a patient’s capacity to absorb, are all necessary in order to achieve good outcomes.10 One must find the ideal setting, use the appropriate vocabulary, body language and express words in an empathetic way, which in an obstetric setting can be particularly challenging, given the contrast to the joy that usually surrounds a healthy pregnancy.11 12
These encounters and the patient’s responses are unpredictable and, quite naturally, involve an immense range of emotions.13 The degree of distress the conversation induces can also be heart-breaking for the medical professional. Doctors describe it as one of the most difficult tasks they engage in clinically and some report immense levels of stress, fear and anxiety.14 In extreme cases, this can have an adverse impact on their clinical and communication performance, and affect the clinician both physiologically and psychologically.15
Some doctors feel the only way to protect themselves in these situations is by forming a barrier between themselves and the patient. However, when breaking bad news to a family member these tactics disintegrate. To be honest and direct with a family member requires even greater reserves of strength, and delivering news of a poor prognosis is almost impossible. In these settings, it is the empathy that gets you through, using your emotional connection and not logic.
Returning to work after a family tragedy is one of the final tasks to be accomplished. Some find the strength by seeing it as a rewarding life experience, but others find it mentally draining and rely on external assistance to ease them slowly back on to the right track.16
Either way, we must recognise that the physician-relative scenario is a unique one: stressful, emotional and challenging. The flashbacks that can occur for the remainder of your career have the ability to catch you off guard and you must look after yourself accordingly. Whether this final step involves counselling or confiding in a mentor, it is important to communicate your feelings and have a plan for the aftermath as you move forward.17
To this day, I still question my actions of that evening. Did I do the right thing? Did I interpret the implied consent correctly? Should I have played the role of a sister, ignored my medical professional instincts, and just joined them in desperate waiting while the events unfolded? Or would that have provided false hope and merely delayed telling them the inevitable?
Doctors will always be family members and the value of our emotional attachments should not be dismissed, but we should be made more aware of these conflicting expectations and the challenges that may arise from being the doctor in the family.