A 48-year-old man with an extensive smoking history is evaluated for cough and an episode of mild hemoptysis. After the patient ignored his symptoms for weeks, his wife finally convinced him to make an appointment. Chest x-ray reveals a mass lesion in the right upper lobe. A chest CT scan and bronchoscopy with biopsy are scheduled for that afternoon, and the patient is instructed to schedule a follow-up visit with the physician 3 days later to discuss the results. The patient agrees to have the tests done but declines the follow-up appointment, saying that he and his wife are leaving for a previously scheduled week-long anniversary celebration and vacation the next day. Despite education about diagnostic possibilities, he is convinced that his symptoms are stress related and that he will feel better by the time he returns. The physician is highly concerned that the workup may show lung cancer although the patient clinically appears to be stable. Which of the following is the most appropriate response by the physician?

Question

A 48-year-old man with an extensive smoking history is evaluated for cough and an episode of mild hemoptysis.  After the patient ignored his symptoms for weeks, his wife finally convinced him to make an appointment.  Chest x-ray reveals a mass lesion in the right upper lobe.  A chest CT scan and bronchoscopy with biopsy are scheduled for that afternoon, and the patient is instructed to schedule a follow-up visit with the physician 3 days later to discuss the results.  The patient agrees to have the tests done but declines the follow-up appointment, saying that he and his wife are leaving for a previously scheduled week-long anniversary celebration and vacation the next day.  Despite education about diagnostic possibilities, he is convinced that his symptoms are stress related and that he will feel better by the time he returns.  The physician is highly concerned that the workup may show lung cancer although the patient clinically appears to be stable.  Which of the following is the most appropriate response by the physician?

Quizplus · Accepted Answer

In this situation, it is highly possible that the patient will subsequently receive bad news about his health from the physician. The patient is in denial and his condition may be serious (ie, probable lung cancer). However, he appears to be clinically stable and a week's delay is unlikely to affect his treatment outcome. The best approach is to respect the patient's defenses at this time and arrange for a follow-up on his return. When delivering bad news, a face-to-face visit in a comfortable private setting is preferred as it allows the physician to respond to nonverbal aspects of communication and provide empathy and emotional support as needed. It is also important to assess the patient's understanding of the condition and how much the patient actually wants to know. Other steps include gaining an understanding of cultural/educational/religious issues, making medical information understandable to the patient, and formulating a collaborative treatment plan (SPIKES protocol). SPIKES protocol (Choice A) Attributing his symptoms to stress may be the patient's initial way of coping with expected bad news. It would be inappropriate to confront the patient with his denial at this point. If and when a cancer diagnosis is confirmed, the news should be delivered in a sensitive manner. (Choice B) It is premature and insensitive to provide the patient with a "probable" diagnosis of cancer before the workup is complete. Not having a definitive diagnosis is likely to cause uncertainty and unnecessary alarm. (Choice C) The benefits of the patient going on what might be his last vacation outweigh the minimal risks of delaying his treatment for a week. In addition, asking the patient to postpone his vacation in the face of his denial, without clear evidence of a diagnosis, may negatively affect his future engagement with the physician. (Choice D) It is premature and inappropriate to bypass communication with the patient and call his spouse. All preliminary communication should still be directed to the patient. (Choice E) Contacting the patient by phone would not be the most appropriate method for communicating serious news. Face-to-face meetings are more appropriate for delivering bad news. Educational objective: Delivering bad news is optimally done in a face-to face meeting that allows the physician to better assess the patient's emotional reactions and provide empathy and necessary support. References: SPIKES: a framework for breaking bad news to patients with cancer. (http://www.ncbi.nlm.nih.gov/pubmed/20682509) Physician-patient communication: breaking bad news. (http://www.ncbi.nlm.nih.gov/pubmed/22655433)

A 48-Year-Old Man with an Extensive Smoking History Is Evaluated