The Double-Edged Sword of “Brutal Honesty”

“I don’t mean to sound harsh. And I owe you honesty.”

I almost always say this when I speak to families about the condition of their critically ill loved one. Usually, when I say these words, my patient is very sick, and they are at high risk of dying. I have lost count how many times I have said the above words to families of patients suffering from COVID-19.

Most recently, I said these exact words to a family who was grieving after their mother, suffering from COVID, just got placed on a ventilator. She had been sick for a long time, and now that she required mechanical ventilation, her prognosis was likely very poor.

I did not pull any punches with the family. I gave them “brutal honesty” about how their loved one was doing. I told them that, while I do not want to crush all hope, I also did not want to give them false hope, which was much worse. I could tell they did not like what I had to say, and – to be honest – I didn’t feel right after our interaction. For some reason, I was may more blunt than usual.

The following day, I got feedback that the family really didn’t appreciate they way I spoke to them. They felt that, as a physician, I should have had more compassion for them and their situation. The nurse, in fact, told me I probably should not go in the room with the family present. I felt I had to rectify the situation, repair the damage to our relationship. And so, I went in the room and spoke to them again.

I said that it is essential that we – myself and my patient’s family – have a good relationship because, we are a team, and if we don’t work well together, then my patient – their loved one – will ultimately suffer.

They told me that they didn’t appreciate how I spoke to them, that it made them feel that I had “given up” on their loved one, that I had no hope left or didn’t want to fight for her. This was the worst day of their life, and my interaction left them wondering what kind of physician I was to whom they left their loved one in his care.

I listened to this “brutal honesty” about how I acted, and I apologized. I didn’t mean to come off this callous and uncaring. I totally understood how they were made to feel, and that was never my intention.

I told them that, if I didn’t care, I would not be there the bedside. I thought about leaving medicine, I told them, but I never did because, I really do care. They were very appreciative of what I said, and I felt we were able to establish rapport once again.

I still believe in being honest, sometimes brutally honest, with my patients’ families. I truly believe that giving false hope is the absolute worst thing I can do as an ICU physician. At the same time, there is a balance between honesty and compassion, and my recent interaction taught me that.

Although I have seen the movie of how critically ill patients with COVID fare time and time again, my patients’ families have not seen it before. For them, seeing their loved one get worse and need a ventilator is the worst moment of their lives. I need to be more cognizant of this fact and do my best to deal with families in a gentle manner.

That doesn’t mean I sugar coat how my patient is doing. I will never do that. At the same time, I need to make absolutely sure I do not come off as if I could care less about their loved one. I need to make sure that I am not conducting myself as if to say, “Why even bother?” It can be a tough tightwire to tread, but tread over it I must as a critical care physician.

We are all exhausted. We are exhausted from the relentless death, destruction, and despair wrought by this pandemic. We are frustrated at the senseless death, especially now with widely available vaccines. People need to understand that. At the same time, it is as important – if not more important – that we understand that our patients’ families are devastated when they see their loved ones crash with COVID. We need to be careful not to be brutally callous in the attempt to be brutally honest.