Health Care Promises: Look Before You Speak

In the face of a serious illness where a recovery is not likely, such as terminal forms of cancer, end stage heart failure, end stage emphysema, or a profound stroke, fear and uncertainty are prominent emotions. Family and friends, in an effort to provide comfort and reassurance, may make promises that are unwise and often unnecessary. If those promises need to be breached - especially in the assembly of future and unanticipated care - everyone's distress is increased.

Promise #1: "I will never put you in a nursing home."

Substitute: "We will do everything we can to make sure that you get the care that you need, but can make no promises about a nursing home at this time."

Many older people have understandably poor images of nursing homes based on their experiences. They worry about abandonment, dignity, and the potential for suffering. To them, nursing homes are where people go to die, often alone. Many modern nursing homes have multiple capabilities and are appropriate locations for transitional care that may include rehabilitation from surgeries or other illnesses where a prolonged stay is needed. They may also be associated with assisted living facilities and apartments to ease the transition to independence.

To help manage the stay, there are case workers assigned to each person who helps assemble a treatment plan, deals with insurers and Medicare, and can greatly facilitate progress to and from different levels of care. There are ample opportunities for family and friends to visit and when possible, for the person to leave the nursing home to go out for dinner, to a movie, shopping or to a family member's home.

Promise #2: "We will make sure that you do not suffer."

Substitute: "We will do everything that we can to keep you as comfortable as possible."

Despite everyone's best effort, there are elements of suffering over which we have little or no control such as sadness, loneliness, and fear. While there is much that can be done to address physical pain, some pain, such as that associated with some procedures, may be unavoidable.

The management of physical pain with medications also requires periodic adjustments that may result in brief periods of unwelcome discomfort and some periods of painful sensation as appropriate doses and selection of pain relievers are tried. Often, one of the key concerns of patients at the end of life is a fear of abandonment that they believe will result in unbearable pain that may lead to a request for assisted suicide. Those requests were withdrawn when they were told that they would not be left alone and that every effort would be expended to meet their need for pain medication.

Dying and the ultimate reality of death yields many questions that may not be immediately easy to answer. Rather than reflexively responding to the request of the person with the illness, instead ask more questions to learn more about the fears that a person is experiencing and carefully offer the comfort and support that you can at that time.

Do not make spur-of-the-moment promises that may only create problems as time and the disease progresses. Dying is a dynamic process that can take unexpected twists and turns. Everyone's distress is increased when options that can be helpful have been taken off the table before the full extent of the illness reveals itself. Ultimately, one must do what is necessary, even if that means breaking an early promise that was made with the best intentions.

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