Recently I rotated through the intensive care unit, where we care for the sickest of the sick, and where patients often teeter on the brink between life and death. On the first day, I met two patients, both elderly gentlemen. With one patient, I had lengthy conversations with him and his family. We joked about jet skiing, one of his favorite summertime hobbies. The second patient was on a ventilator, unable to speak. With this patient, I squeezed his hand, and he would blink back at me. I was unsure whether he had a million things he wanted to tell me or whether he was delirious, a state of confusion relatively common in the ICU.
However as the month progressed, the first patient took a turn for the worse, developing sepsis, fungemia, and respiratory compromise. The patient had to be intubated, meaning a breathing tube was placed down his throat, and he was no longer able to speak. I could still communicate by having him write things on a whiteboard, but for most purposes, our ability to communicate had been cut off.
As I rotated off of service at the end of the month and the new team came on to take care of the patients, I noticed that the new team members had no context for who this patient was as a person. They weren’t aware that he could tell a dirty joke, how optimistic an attitude he possessed, and how much he wanted to get home. The team still took excellent medical care of him, but so much of that personal connection in the patient-doctor relationship was lost. It was a very similar situation, unfortunately, to how I treated the second patient I met at the beginning of the month.
There is no true solution to the problem of dehumanizing a patient who cannot communicate. If a patient presents to your clinic, emergency room, or ICU in a state where they are not competent to communicate, there are a limited number of ways for us as providers to engage with them. But after my experience seeing how, in some ways, we dehumanize patients who lack capacity, I developed three ideas.
My first realization is that we need to try to communicate with these patients if at all possible. Often, for me, this meant the painstaking process of an old weak man slowly writing out words on a whiteboard, but it was essential to bring his story into focus for me as a provider. Second, we need to piece together a patient’s personality from as much evidence as possible; this includes stories from family members, old clinic notes, or previous care providers. And lastly, we need to use our imaginations more. I’m ashamed to say it, but with the patient who was intubated at the time I first began on ICU service, I think a subconscious part of me assumed he was always like that. I lacked the imagination to assume he had the same dirty humor as the other patient, or the same strong desire to get back to his home to see his dogs. When patients lose their voice, we have to find it.