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What I learned dealing with patients’ relatives over 25 years

​When I was in medical school, I learned how to treat patients and manage their medical conditions. But during the five-year course, I was barely taught how to manage their relatives.

The writer says he is mindful of patients' emotions when communicating with them, but the challenge comes when relatives are in different mental states and try to influence the patients.

The writer says he is mindful of patients' emotions when communicating with them, but the challenge comes when relatives are in different mental states and try to influence the patients.

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When I was in medical school, I learned how to treat patients and manage their medical conditions.  But during the five-year course, I was barely taught how to manage their relatives.

In my medical practice in the last 25 years, I have learnt that managing patients’ relatives is just as important as managing patents.

If the relatives do not agree with me, the patient may not follow my treatment recommendations, and may not even turn up for follow-up consultations.

Relatives may also file complaints to the Ministry of Health, Singapore Medical Council, or air their unhappiness on social media.

So how can doctors overcome the challenge of managing patients’ relatives?

According to Elizabeth Kubler-Ross, a renowned psychiatrist, there are five stages of grief: denial, anger, bargaining, depression, and finally, acceptance.

I am always mindful of patients’ mental status and stages of grief.

For instance, if patients are angry or depressed after being diagnosed with liver cancer, it is best to offer them comfort and empathy.

The challenge comes when relatives are in different mental states and try to influence the patient.

I once had a patient with suspected metastatic cancer. He was understandably depressed and declined further investigations. His daughter kept asking why her dad was so unlucky to have advanced cancer.

His son-in-law wanted to take the patient to top cancer centres in United States for a second opinion. The patient’s son was the most logical one as he accepted the diagnosis and wanted doctors to move on to confirm it and treat the condition accordingly.

The patient refused any treatment and was re-admitted several weeks later due to further complications. Though my colleagues and I managed his complications, he refused treatment for the cancer and eventually passed away.

It is common that within a family, relatives may prefer different treatments.

For patients with liver cancer, this could be surgical resection, liver transplant, local regional ablation, systemic treatment, or even no active treatment.

Each treatment has its pros and cons, with different costs and side effects involved.

While liver transplant has the highest curative rate, it is costly and risky. Radiofrequency ablation is cheaper and safer, but the cancer may recur.

It is the doctor’s job to explain all these clearly to the patient and his family so that they can make an informed decision.

Some relatives may turn emotional, irrational and even abusive at times, especially when they see their loved ones suffer. When emotions run high, it may not be possible to have a logical conversation with them.

Healthcare professionals must know when to engage them and when to just offer empathy.

To gain the trust of patients and their relatives, doctors must demonstrate not only competency but also compassion.

When I became an associate consultant 17 years ago, I often received complaints from relatives for my poor communication skills. They lamented that I spoke too fast and I did not update the family adequately.

Fortunately, I had good mentors in Professor SG Lim and Associate Professor KG Yeoh. After much coaching by them and some self-reflection, I started to receive more compliments than complaints.

My practice now is such that at the first consultation, I usually ask the patient who the representative of the family is.

I would inform the representative that I would explain to him the condition and treatment options and he should inform the rest of the family.

So any subsequent queries from relatives about the patient’s condition or treatment options would be directed to the spokesman, reducing the need for me to explain the situation to multiple relatives separately.

But it is not always so clear cut, as some relatives are not on talking terms.

In any case, I make it a point to keep the family updated as much as I can. This is particularly important in patients who are more ill and whose condition may change drastically.

For important updates or key decision making, I would ask the spokesman to gather the whole family to meet me at my clinic so that I can answer their questions and they can reach a consensus on the preferred treatment.

To manage the family effectively, it is important to know the patients’ conditions well.

In my case, hospital nurses will update me through WhatsApp and phone calls. I can also see my patients’ laboratory results, imaging studies, and parameters via apps.

It is bad if relatives discover things that the medical team is not aware of.

For example, my nurses and I will be doing a lousy job if the relatives could tell us that the patient has been vomiting for a day without me knowing it.

As the attending doctor, I cannot let relatives surprise me with information of the patient. Trust from relatives has to be earned this way.

In communicating with the relatives and patient, it is important to set their expectations right on the condition and treatment outcomes. Of course this is sometimes easier said than done.

For instance, the health of a patient with metastatic liver cancer will gradually deteriorate, marked by acute incidents such as confusion, bleeding, and infection.

If I prime the relatives well, they would see these episodes as part and parcel of the disease. Otherwise, the family may think I made the wrong diagnosis and gave the wrong treatment.

In this age of social media, it is easy for people to use these platforms to criticise healthcare professionals and their organisations. Although most of the posts reflect the genuine perceptions and feelings of the family, they provide only a one-sided account.

Medical staff and hospitals are bound by medical ethical guidelines in not releasing patients’ information publicly without patients’ consent.

I have accepted that being criticised publicly is part of my job as a doctor, even if some criticisms are unfair and lopsided. Doctors do not respond publicly as the ethical code forbids us from doing so.

Although I won’t take criticism too personally, I do look at it as a learning opportunity to do my job better in future.

To conclude, managing relatives requires a different set of skills that are currently not well taught in medical schools, and even in postgraduate education. Relatives who are hostile or untrusting present a big hurdle in the treatment of patients.

It is time healthcare professionals receive better training in this important area.

 

ABOUT THE AUTHOR:

Dr Desmond Wai is a gastroenterologist and hepatologist in private practice.

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