Exploring how to tell the truth and preserve hope: can a balance between communication and empathy be calculated?

Modeling lengthy work-ups in gastrointestinal bleeding

Multiple procedures and medical devices are being used in a complex interplay to diagnose and treat gastrointestinal bleeding. The aim of the study was to develop a mathematical model that helps in estimating the average number of procedures to be expected in the general management of gastrointestinal bleeding. The modeling process serves as an example of how mathematical analysis in general can be used to answer unresolved clinical questions, lead to a better understanding of the underlying influences in a disease process, and provide a starting point for future clinical trials. The analysis uses a Markov chain to model the transition probabilities among consecutive interventions used to find and treat a bleeding site. The results show that starting a work-up of gastrointestinal bleeding with an esophagogastroduodenoscopy will lead on average to 2.69 procedures per patient. Of these expected procedures, 1.46 will be esophagogastroduodenoscopies, 0.69 colonoscopies, 0.25 video capsule endoscopies, 0.14 double-balloon enteroscopies, and 0.14 procedures from interventional radiology. Management chains initiated with a colonoscopy result in similar outcomes. Among 10,000 simulated individual patients, the number of procedures varies between 1 and 16 consecutive procedures, with 95% of all patients undergoing 6 procedures or less. The outcomes of the model suggest that the published success rates of endoscopic and radiographic procedures are overly optimistic. The results also point to the need to generate clinical data through future studies that more reliably account for treatment failures and the interchange among various complementary diagnostic modalities.

How to predict the future (outcome of gastrointestinal disease)

This short review is aimed to illustrate three simple rules to predict the outcome of a gastrointestinal disease. The first rule relates to the principle of WYSIWYG, that is, "what you see is what you get." To predict the future of a given digestive disease, the gastroenterologist needs to pay close attention to its present appearance and develop clear understanding of its pathophysiology. To delineate future trends, as a second rule, the gastroenterologist needs to delineate past trends and try to extrapolate them into the near future. Third, the length of the past medical history also provides a reliable estimate for the expected future lifetime of a gastrointestinal disease. These rules enable gastroenterologists to enlighten themselves, as well as their patients, about the future outcome of a given gastrointestinal disease.

Perspectives of Elderly Veterans Regarding Communication with Medical Providers about End-of-Life Care

OBJECTIVE

To explore patients' perspectives concerning communication with medical providers about end-of-life (EOL) care.

DESIGN

Cross-sectional survey involving semistructured interviews.

SETTING

Outpatient primary care clinic of a large, urban Veterans Affairs (VA) Medical Center.

PARTICIPANTS

Male and female veterans who were 60 years or older, ambulatory, able to speak and read English, residing in the community, receiving outpatient care from the VA, not acutely ill (i.e., not hospitalized or in obvious distress), and not cognitively impaired.

METHODS

During audiotaped interviews to assess understanding of advance directive concepts, all 30 participants were asked what advice they would give medical students or trainees about how to discuss EOL care with patients. The audiotapes of their open-ended responses were transcribed, coded, and examined using qualitative content analysis, a systematic and replicable technique to uncover meaning by detecting commonalities and regularities of speech.

RESULTS

Seven essential elements of advice for medical providers emerged: engage in strategies to ensure patient understanding (mentioned by 30% of participants), communicate honestly and truthfully (27%), develop a compassionate bedside manner (27%), treat others as you would want to be treated (20%), provide empathic care (20%), take the time needed to communicate (20%), and determine patient information and decision-making preferences (17%).

CONCLUSIONS

Effective EOL discussions with patients require attention to the content, process, and perception of patient-provider communication.