JOURNAL OF PALLIATIVE MEDICINEVolume 9, Number 2, 2006© Mary Ann Liebert, Inc.

The Unexpected Team Member

DONA LESKUSKI, D.O. and SUSAN B. LEGRAND, M.D.

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“GOOD LUCK,” were the parting words of mysupervisor. I was on my way to partici-

pate in a family meeting that was expected to bea challenge. The patient had incurable diseaseand had exhausted his disease-specific treatmentoptions. He had stated to one team member thathe wanted to stop aggressive measures but wasnot competent to make choices. Clinically wethought he was dying. The purpose of the meet-ing was to establish new goals of care, with theprimary focus on comfort.

Being a new fellow in palliative medicine myconcentration was directed toward accomplish-ment of the assigned task. I had a script that I haddeveloped over the previous few meetings: in-troductions with informal conversation duringwhich I would establish rapport, find commonground, fire any “warning shot” of bad news tocome, cover the agenda, answer questions, andestablish a plan of care from that point forward.It was a system that had worked well for me; Ihad no doubt it would do so again.

They were all present—wife, children, sisters,brothers. There was even a brother from out ofstate on conference call. The patient was too ill toattend. Introductions were pleasant, as were afew words of conversation. We were off to a goodstart. Nothing could have prepared me for whathappened next.

As the meeting moved into the more formalphase an amazing transformation took place. Po-lite smiles became tight lines. Previous tones ofpleasant conversation were replaced with harshand aggressive demands for interventions thatwould not be helpful and would potentially addto the patient’s discomfort. The family deliveredeach statement as an angry blow. Questions were

intoned as accusations. The unstated imperativewas, “We are going to make you save his life.”They were a family in crisis and on the attack.

I tried simply letting them vent. I tried the “Ihear” and “I wish” statements. Everything I didseemed to fuel, rather than quench the fire. I wasessentially paralyzed, unable to do more thanmerely survive the tongue-lashing. Statementsthat were clearly exaggerated were not chal-lenged as I tried to avoid increasing the anger.Eventually I agreed to some of their requests butinstead of helping the situation, it seemed to jus-tify their approach and they became more ag-gressive. There would be no common ground.The rest of the hour was a disorienting blur.

The meeting left me utterly beaten. What hadgone wrong? Why were they so angry? Whydidn’t I know how to make them less angry? Ithought a great deal about it over the next fewdays. Ultimately I realized my trouble had comefrom an odd source: me. I had underestimatedthe impact of my personality and its contribution.My coping mechanism in very stressful situationsis to smooth ruffled feathers, doing whatever ittakes to connect and diffuse a volatile situation.This time, however, it was an impossible task.Robbed of my usual coping strategy I was deadin the water. I literally did not know what mynext action should have been.

In every doctor–patient encounter there is ausually overlooked but very influential party: theperson behind the medical degree. As doctors wehave years of training in medical facts uponwhich we rely to govern our interactions. Intel-lectually we can feel we are somewhat detachedwhen imparting information, regardless of howcompassionate the delivery. We neglect the fact

The Harry R. Horvitz Center for Palliative Medicine, Taussig Cancer Center, The Cleveland Clinic Foundation,Cleveland, Ohio.

*A World Health Organization Demonstration Project in Palliative Medicine.

Personal Reflection

that although we are acting as professionals weare also human beings vulnerable to the dynam-ics of communication. In many situations, it is ourown background of strengths, fears, habits, andmechanisms of coping that drive the exchange.

Often our natural inclination is to put the lesssuccessful communication experiences behind usquickly and simply move on. This is an unfortu-nate disservice to our professional development.Examination of not only the exchanges them-selves but also of the contribution of our person-ality traits can help us understand the “why” behind the “what” of each interaction. Such self-reflection is key to developing a viable personalstrategy for functioning under, instead of beingheld captive by, uncomfortable circumstances.Ultimately, this can mean the difference betweenhelping or alienating a patient.

Having had the luxury of hindsight and re-flection, I would make some changes to my ac-tions that day. Clearly there was no way to ac-complish my intended task with the dynamics asthey were. Nothing would have changed the fam-ily’s views but exploration of them may have

been invaluable. While heated confrontation isnot one of my strengths, asking questions calmlyis. In my re-do scenario I would ask about theanger itself. I would challenge incorrect state-ments that further inflamed others. I also wouldnot try to carry the meeting alone. There wereother team members present that day who couldhave helped; this time I would let them.

These changes certainly cannot guarantee thata turnaround would have occurred. Yet in retro-spect I believe we could have discovered as ateam some way to help this family that I couldnot do solely under the influence of my own per-sonality.

Address reprint requests to:Susan B. LeGrand, M.D.

Harry R. Horvitz Center for Palliative MedicineTaussig Cancer Center

The Cleveland Clinic Foundation9500 Euclid Avenue

Cleveland, OH 44195

E-mail: legrans@ccf.org

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