BARRIERS IN COMMUNICATION – A KÜBLER-ROSS PARODY OR RAMIFICATIONS OF THE BENIGHTED?

By Dr. Geeta Sundar

The counselling sess is in full-flow. There are 6 sets of scrunched faces, drooping chins and whitened eyes staring at me. I’ve spoken the whole she-bang, the ups and downs, the benefits, the risks…nothing more left to say, really as I conclude my statements in their understood local language about the need for surgery for the patient. There lies a paper of scribbled anatomy on the table that separates us, intricate dawdling of my broken up, written-in-a-hurry handwriting. A few faces stare at the paper, few others at the mask coating my face, a few others look around, or their phone. The small room hardly gives me space to breathe deeply, its congested with 7 beings and it’s a tight enclosed space with backed up chairs with no room for scraping. If I may state, they are in my personal space, and I don’t like it much. But I put on a brave face for whatever comes along – its in my training to do so.

“Any doubts?” I ask in trepidation.

A whole lot of people want to speak up. “But, will he be alright?” “Are you sure the surgery will be a success?” “What happens if he can’t recover?” “But, everything else is fine?” “But, once the surgery is done, he will be alright?”

I swear, if I hear “will be alright?” again, I’d start putting pennies in a jar which would lead me to have a trust fund for a few lifetimes! I am exasperated. What in the world does “alright” mean?

I try with all my calm might to explain that the situation is dire, no one can predict outcomes in a M4 response patient that clearly but we think that emergency surgical intervention can provide him a better chance at survival. I feel the words bounce off their heads, like tangents. The words just won’t make their mark. I scan for the most well-read person or the person with the most ability to comprehend the grief, and I focus on her. She gives me a small nod as if she gets my reiterated words, but it’s a lost cause, I can’t see her body language accepting of the words or the reality and she is not helping me convince the rest in the room.

This lot will have a hard time understanding the implications. I try to wrap up as best as I can and push for the consent from the son of the patient, who thinks for a while, and then shakily signs on the dotted line.

Dusted. But a long cry from anywhere being accepted.

Middle aged man, all of 52 years, comes with headache and blurred vision. MRI picks up a right sided lesion sitting in his occipital cortex causing edema. Looked like a bled metastatic lesion. We counselled him on surgery and excision. The wife of the patient had many concerns – “Why, him?”, “Why, now?”, “Where is it coming from?”, “Why did it happen to him? He has no hypertension or diabetes; his health is very good.” “Is it related to food?”

Or in another scenario, a twenty-eight year old male with nil premorbid was admitted with left capsule-ganglionic bleed, only to be diagnosed as young onset refractory hypertension. A lot of workup showed his metanephrines were elevated and treatment was enhanced accordingly. The mother was beside herself – “Its all related to food, isn’t it?” “He likes spicy food, and oily roadside items.” “He is young, not yet married, now with right side weakness and slurred speech. Who will marry him?”

Almost always, everyone thinks its related to food intake. But no one thinks its related to smoking or alcohol intake, or drugs, or genetics. How do you explain multifactorial influences for brain mets to an illiterate guarded wife who thinks that her virtue is being questioned as her husband has some unspeakable disease that she only knows of from TV shows and sappy cinemas? Or how to do calm down an agitated mother that her son has been inclined genetically for a disease that is causing his BP to shoot up and its not related to enjoying a ‘bhaaji’ on a whim?

Makes me want to question – if people understand the implications of food in their lives, given that the blame is first to the food they consume, then why do they still eat recklessly, and not pay attention to what its effect can be? Any guesses?

Often times, patients in the ICU face ‘hospital-acquired’ infections – urine, tracheal, and from catheter lines. In the innumerable talks we have with families explaining about the manifestations of sepsis and its complications, the only message sent across is “septic”. A glorified word, it takes countless forms and meanings.

“Septic” encompasses fever, febrile seizures, headache, infection, shock, bad heart rate, bad breathing, bad chest, bad blood, bad urine, diabetic ulcers. For a blame, everything is ‘septic’. Patient families inform their friends and other relatives that their patient is in a bad condition because of ‘septic’. ‘Septic’ gives an easy way out – blame the bug. Blame the infection. Blame the organism that created the problem. Blame, blame, Blame. But don’t ever prod and inquire into that bottomless thought inside you – was it ever because of what you did in the days before getting admitted to ICU that caused this redundant failing immunity? So that ‘septic’ could get you?

Ouch.

As a doctor I am not keen on medications. As a surgeon, taking medicines makes me cringe. I am not fond of gurgling and swallowing big capsules that can constrict my pharyngeal space. I understand pain is an intuitive feeling and that thresholds are not easy to conquer and so analgesics are mainstay of any hospital admission. But somehow, the concept is a goner on the patients. There is some ardent internal belief that the more medications you take, the more the capsules you consume, the better you will get.

With all due respect where its required, anti-epileptic drugs needed and will help you and make you better. And so, will other anti-infective medications, steroids and other life saving medications. But I draw the line at ‘gastric’ (which acts like a step-brother to septic), and ‘nerve-strengthening’ medications. Oh, but c’mon, see the vision with me here. How does adding a GABA modifying agent or a multi-vitamin increase appetite or help in nerve conduction in a plegic patient?

But the request is always there. “Doctor, give me ALL the medications.” (As if I won’t, as if I’d give you anything less than what is required?)

“Doctor, add a medication for improving sleep.” “Doctor add a medication for improving his nerves.” “Doctor give me something for the gastric.” “Doctor add something for improving vitality and appetite.”

The whole agenda of poly-pharmacy is exhausting. I’m not a fan. I don’t indulge in it, but sometimes, when the requests are too begged, one has to oblige. Frankly speaking when I see patients walk in with a basket full of medications, it makes my heart wrench. And tie up in sorts, especially when I think of the side-effects they will have. 2 to the power of the meds they are on!. The media portrays that medications offer relief, and boost strength and that gets translated into the hordes of minds that watch it. Nothing ever replenishes healthy, fresh, well-balanced home cooked meals.