When there’s bad medical news, many people ask: ‘What are my chances, doc?’ But often we develop blind spots for poor outcomes. Margaret Schwarze in the New England Journal of Medicine suggests scenario planning as a great way forward for this.
Dr Schwarze describes a very active 87 year priest, Father Andrew, who goes out for one if his usual drives. But wakes up in the Intensive Care Unit with a tube down his throat, and more tubes in his chest. He has multiple broken ribs and — even worse news — they’ve found cancer spreading through his chest.
The doctor looking after Father Andrew knows that, with his age, this man’s chances of dying just from his many broken ribs are 90%.
Father Andrew’s first question was when he was going to be able to drive again.
This is where doctors often part company from patients and their families.
Sometimes this is because of poor understanding of numbers by patients. The most extreme example of this that I know of was a woman who was counselled that she had a 1 in 2 chance of any children having a rare and always-fatal genetic condition. She wasn’t worried by this — explaining to the doctor (it wasn’t me) that it was just like the lottery, you either won or lost. And she’d never won anything on the lottery, despite doing it for years. So she thought it was all going to be just fine. The doctor realised this lady needed a better explanation
It’s not only patients who don’t always quite understand probabilities. My own work has underlined how many doctors don’t know actual CPR survival rates.
Father Andrew thought he had a 10% chance of getting back to normal. “He’s a fighter”, his sister told the doctors. But all the fighting in the world wasn’t going to get Andrew back to normal.
Instead of percentages, another approach would be to use scenario planning to think in terms of the possible outcomes. Thinking like this can “help patients look beyond isolated risks to imagine a new potential reality”.
The best case scenario for Father Andrew would mean that he might leave the hospital. Before then, he “would need ventilator support for many days. He would have pain and be unable to talk to his family. He might gain enough strength to be extubated, but given his age and pulmonary function, he would never regain the independence he has enjoyed.” After his discharge, of course, his cancer would continue to grow. With it affecting his breathing, he would “need substantial nursing care; he would never drive again, and he would die.”
The most likely case, was that “he would improve somewhat, but would ultimately struggle to breathe on his own and would die within days.”
The worst case scenario includes lots of fruitless interventions, more pain, less dignity and no communication.
Father Andrew chose to be extubated and talk to his family. Communication with others was, after all, his life’s work. He “died later that day, surrounded by family.”
I think the scenario planning approach could really help in discussions about CPR and DNACPR orders.