Physicians' Self-Defenses Can Interfere With Patient Care

OWINGS MILLS, Md--"I once worked with an oncologist who wouldnot treat a child the same age as his son. One year it was 10;the next year, 11," said Daniel Timmel, LCSW, of the Medicaland Chirurgical Faculty of Maryland (the state medical society)."Defenses are very interesting."

Speaking at a symposium on palliative medicine sponsored by theUniversity of Maryland Cancer Center and the NCI, Mr. Timmel addressedthe question of what terminally ill patients and their familiessay they want from their physicians. His bottom-line answer: honesty,presence, and leadership.

The physician may fail to fulfill these patient desires when hisbehavior is driven by subconscious defense mechanisms againstsuch things as death, anger, and his own sense of mortality, ratherthan by professional knowledge, he said.

Self-defenses can interfere with professional care by causinga physician to avoid a dying person (denying the patient and familythe physician's presence and leadership) or to be less than honestabout the prognosis, Mr. Timmel said.

There are powerful reasons for defense mechanisms, he noted. Thekey is to recognize them and "tell the difference betweenour need and the patient's need."

Honesty: The Best Policy

Patients and their families look to physicians to lay out whatthey can expect. "They haven't been there, and they needsome guidance," Mr. Timmel said. "We often don't knowwhat's going to happen ultimately, but we usually have a goodidea of what is going to happen next. Make sure you don't promisesomething you can't deliver."

Families complain most bitterly when they feel they have beengiven a false sense of hope. "When they've come to some termswith the fact that the patient is going to die and then someonegives them hope, they'll grab at it," he said.

The false hope may arise from genuine disagreements between physiciansor from someone trying to be kind. Nonetheless, he emphasized,"families resent the roller coaster."

Something as seemingly insignificant as downplaying the pain ordiscomfort a person will experience from a test or procedure candeeply affect patients. Physicians may tell a patient "Thiswon't hurt" because they don't want to feel like they areinflicting pain, Mr. Timmel said. "This is a defense, butkeep in mind that it diminishes the patient's trust."

Physicians should also ensure that all family members get thesame information. "It is helpful when you can see the wholefamily system as a unit of care," he added. "Hold afamily conference and let everyone hear the same thing at thesame time, at the bedside, if at all possible."

Physicians may withdraw from dying patients, spending less andless time with them and communicating less with the family. Mr.Timmel said he has literally coached families on how to blocka door and not move until a physician has answered their questions.

A physician's professional demeanor is important. Any genuineexpression of emotion by the physician is appropriate up to thepoint that it causes a role reversal. "If the patient orfamily needs to devote their energy to comforting the physician,that is over the line," he said.

Mr. Timmel explained that years of experience have taught hima simple lesson about being with grieving families after a death.Listening is usually more important than anything one can say."I try to just be there and not say anything stupid,"he said.

Patients and families look to physicians to guide them throughthe dying process and to serve as team leader. This means marshalingmedical services and directing others in caring for the patient.

"Get people on the case who have the training to ease thedying patient's passage," he advised, "and see thatthe family gets information on community services, including theavailability of hospice facilities."