The Lessons Learned from Patients We Didn't Help

Abstract

This short narrative is a reflection of an unintended, adverse outcome, and the lessons to be learned.

A career in medicine often involves sharing the highs and lows of life with our patients. When we choose a profession in oncology, we certainly accept that some of our patients will not be cured of the disease. In most cases, the process from diagnosis is gradual, with opportunities for us to provide treatments, support, and discussions at various stages. We have time to prepare our patients (and ourselves) for the outcome. The literature is filled with data and nomograms regarding expected outcomes for any malignancy. Although these data are extremely important to shape overall treatment paradigms, we all encounter situations in which we feel that the data have failed us. A sudden death always feels like a punch in the gut.

I recall one experience vividly. I was working away from one of my regular locations when I was messaged about one of my patients. She was undergoing pelvic radiotherapy, and I was called to report she was not feeling well. She was evaluated in our office and was noted to be hypotensive. She was ultimately admitted for intravenous hydration and further imaging. I agreed with this plan and thought nothing more of it. I would make sure to check on her the following day.

When I came back to my clinic the next day, I logged into the electronic medical record (EMR). I found her name easily, but at the top of her chart, the word “EXPIRED” was listed in red. “What expired?” I thought to myself. I thought it referred to a medication that required renewal, or maybe that her code status (made during a prior hospitalization) was no longer valid, or perhaps we just needed a new copy of her insurance card? It took a few more clicks before I realized that SHE had expired. It took even more time for me to process what had happened. At the time of admission, her bowel sounds were absent. A STAT abdominopelvic computed tomography (CT) scan demonstrated pneumatosis intestinalis, a finding consistent with bowel ischemia. Emergent surgery followed, but she could not be saved. She passed away just hours before I came in. A person so full of life was gone. Even now, my immediate reaction—aiming to find an alternative explanation to the word “expired” in the EMR—was akin to the denial stage defined in the Kübler‐Ross model [1]. My mind raced in the intervening hours after learning my patient had died. Although the data may have supported the use of radiotherapy, I wondered whether there was something I missed. Should I have focused more on her underlying vascular disease? Maybe her past medical, surgical, and chemotherapy history placed her at a higher risk of having a complication? I may have thought the treatment being provided was in her best interest, but I couldn't help but think that she may have had a better outcome had we never met. I could not stop myself from wondering—how could I have seen this coming?

Faced with this need to better understand what happened, I went back to my charts the following day to systematically review her case. I went over her CTs and the operative notes, and restudied the radiation treatment plan I had crafted. It was disheartening to go back in time with the hindsight of what had occurred, but I find there can be valuable information derived from reviewing such clinical events. Was there something we could have done differently? Or perhaps was this a stochastic [2] complication of radiation therapy, and not necessarily related to the dose she had received? Maybe this event was destined to happen, and entirely unrelated to treatment? At the end of the day, I could never be sure. My colleagues within the department provided an immense amount of technical—as well as emotional—support. I did walk away from this with the self‐assurance that I did my best and that her treatment was reasonable.

As radiation‐oncologists, we use our knowledge of anatomy and physics to sculpt a radiation field with sub millimeter precision. However, once that beam exits the head of the linear accelerator, there is some degree of unpredictability as it pertains to how it will interact with a patient's physiology. Even a very low radiation dose can result in a potentially fatal toxicity. Although “Do no harm” is a central tenet to our profession, any treatment (even the drive to the doctor's office) could result in harm. With that said, I still find it upsetting to think I could be inadvertently hurting someone at any given time. There is literature on what is sometimes called the “second victim” [3] experience—the impact of an adverse patient outcome on the health care provider.

To address the despair of a patient's sudden death, and to reduce the worry about causing potential harm in the future, I find that it is productive to focus on the process forward. I am excited about the enthusiasm associated with quality improvement in oncology. The emphasis on quality improvements programs such as the Radiation Oncology Incident Learning System program [4] has promoted a safety culture within Radiation‐Oncology, and it now feels that speaking about unintended results is not a sign of weakness, but a sign of strength.

By focusing on the processes of care, we step forward toward improving the care for oncology patients. I try to remind myself that the intention of actions should always be focused on improving the well‐being and quality of life of the person in front of me. I owe it to future patients to learn from my experiences with unintended consequences. For the patient who did not benefit from treatment, I will strive to learn as much as possible, so I can better help the next one.

Disclosures

The author indicated no financial relationships.