Written by Larry Stack
Need in medicine describes what is missing and the necessary corrective action (i.e. you need a transfusion), but this wording allows little latitude for discussion with patients and families. However, saying, “Can we talk about what this means and what to do next?” allows for dialogue without presuming the desired course of action.
Lost in interpretation
Need is a clinician’s secret code word which combines our assessment and management of a seriously ill patient into a pithy soundbite. “If her shock doesn’t improve with 2L IV fluids, she will need a central line and vasopressors,” is a soundbite that often occurs with families of seriously ill patients. While medically this is an accurate statement, when presented to a patient or family member in this manner, it does not offer alternative solutions and could inadvertently force a decision that is not fully informed. It is hard to argue against a solution a family member needs.
Using the word “need” in this manner could be misleading when speaking to seriously ill patients and families and may not be in line with their goals and priorities. The word “need” in this context may also cause confusion when later trying to offer other management options. Families might reply, “But you told me this is what they need; now you’re telling me there is another option?” Such miscommunication may create mistrust in further conversations.
The authors suggest an alternative script: “Mr. Smith, your red blood cell level is extremely low. Can we talk about what this means and what to do next?” The phrase what this means… communicates to the patient and family that there is a health change that will likely have a major impact on their lives. “Mr. Smith, what this means is the amount of blood you have lost is so significant that your heart and brain may not function normally because these organs require oxygen that only blood can provide.” The phrase what to do next provides an opportunity for discussing management options. “Mr. Smith, let’s talk about what to do next. We could give you a blood transfusion to stabilize you until we find the cause of the bleeding and stop it.”
How will this change my practice?
I like the word need. I use it frequently went talking to the admitting team. “I feel this patient needs admission for pneumonia because of hypoxia, dehydration, and mild confusion.” Its use creates a concise picture of my assessment and plan. However, when speaking to seriously ill patients and their families, I will opt to use the language suggested by the authors that more clearly explains the condition and offers management options that align with their goals and preferences.
Reconsidering the Language of Serious Illness. JAMA. 2023 Aug 15;330(7):587-588. doi: 10.1001/jama.2023.11409.