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I attended a conference recently to which I must give the credit for this mnemonic that prompts my memory when faced with difficult conversations: www — wish, worry, wonder.1 The End of Life Nursing Education Consortium (ELNEC) has its own version: the hope-worry statement, which is another great prompt. Both are terrific reminders, but www gives me more latitude in how to approach complicated communications with the families of patients no longer able to say what they want.
CASE
Talking to the family of a loved one at a time of medical crisis can be the most daunting of conversations to have, especially when their expectations do not match the reality of the situation. One such recent patient had stage IV colon cancer. His family barely had a chance to process the severity of his illness when things went south. In a relatively short period of time, he went from good health to a diagnosis of advanced cancer to an adverse reaction to his treatment that resulted in respiratory complications and resultant dependence on a ventilator. He was in the ICU and looked terrible yet his family kept talking about what treatment was next once he got better.
Early in the patient’s admission his family had a conversation with the oncologist where they asked when he could get more chemo. Of course, in their minds the only option was to keep fighting his cancer. The oncologist qualified his answer to the question, “Theoretically, in the best-case scenario, if he gets stronger we could try another chemo.” Although it was possible he could get stronger, it was, at best, a long shot. But what the family heard was “best-case scenario,” which for them translated to the likelihood he could get well enough to get more chemo. They struggled with the context — he had been healthy and strong just a few months before, therefore he had enough strength to get better. His sister even said, “After all, it isn’t like he’s been sick for a long time.” They hung on to the idea of more treatment because it meant he couldn’t possibly be as bad as everyone said he was. Never mind that his cancer was advanced, his response to chemo problematic, and in the meantime, after 11 days on a ventilator, he was getting weaker and weaker. Their hope for good news became their wish and their wish became the only reality they could consider.
