Thursday, September 24, 2020

Obstetrics and Gynecology Needs Palliative Care

by Nathan Riley 

"Can you all, please, just leave us alone?"

One particular experience with the death of a newborn stands out in my mind. Moments after birth the baby was breathless, and the neonatology team could not intubate. All of the kingdom’s pediatric surgeons and other specialists rushed to labor and delivery to no avail. The baby was born with a four centimeter gap in his trachea, an irreparable condition. The mother sat there, holding her dying baby as he took his last breaths while physicians, nurses, and residents were busy as usual. Click-clacking away on computers. Adjusting blankets. Asking questions. Rearranging surgical instruments. This bustle continued until she repeated herself a little more forcefully: “LEAVE US ALONE!”

This experience illustrates how, in a mother’s moment of suffering, a room full of prolific fixers, doers and problem-solvers came up empty-handed. While the loss of a newborn is a relatively rare occurrence, suffering - physical, emotional, psychosocial, or spiritual - is common in the world of women’s health. Likewise, if our only goal on labor and delivery is “healthy baby and healthy mom,” we are without recourse when the normal hazards of being human – many of which are completely out of our control - befall us.

As an obstetrician and palliative medicine specialist, I often wonder how we might approach these challenging scenarios differently. My palliative medicine training taught me that not every problem can - or should - be fixed. My time with patients is often just as well spent sitting in silence as they process the emotions that come with bad news. Even my approach to invasive exams, pregnancy, birth, and pain management is met with an open mind and conversation before putting my steel instruments or medicines to use. After all, a “good outcome” is variable and highly dependent on the patient’s values and goals, and I cannot uphold these values without first building a relationship.

To illustrate how obstetrics and gynecology might be improved through a palliative care touch, let us take a look at one of the most common diagnoses that OBGYNs face in their daily work lives: early pregnancy loss.

Statistically, ten percent of pregnancies end early as a spontaneous abortion or as a “blighted ovum”, in which case the embryo does not develop at all. The diagnosis is thus all too familiar to us providers, but rarely do we consider its gravity on our patients.

The typical clinical routine after a positive over-the-counter pregnancy test is as follows. The patient is greeted on crinkly white paper and positioned in stirrups while the busy clinician offers congratulations. The clinician lubricates and inserts an ultrasound probe into her vagina, swiftly waving the wand around to assess her anatomy. If unable to identify a viable embryo inside the uterus, the clinician resorts to various platitudes to communicate the findings. We are not trained to address anger, sadness, despair, or to consider that this news might even bring relief. In my OBGYN training, my preceptors modeled how to deftly fill any lull in conversation left by the wake of the bad news with generic consolations followed by a list of management options.

Maybe she is facing financial hardship due to the cost of infertility treatments? Maybe this same thing happened in the past and she nearly died from blood loss as a result of a “routine” dilation and curettage? Have you explored whether this is even a desired pregnancy?

A palliative approach to early pregnancy loss would be predominated by conversation, storytelling, and connection, all before a woman is even asked to undress from the waist down. It would include extensive information gathering in order to guide the diagnostic imaging process and align any conversation thereafter with the patient’s expectations and hopes. Early pregnancy failure can be catastrophic to the patient and their partner, and the delivery of this news requires patience and empathy. As with a cancer diagnosis, a patient may not be ready to hear everything that immediately follows the delivery of bad news. With this in mind, it would be better to discuss management options once the patient has had a few moments to process the news, perhaps in an adjacent room away from happily pregnant women or crying newborns. The palliative approach may even include a social worker or chaplain on standby to meet the great psychological, emotional, and spiritual needs for which other clinicians are ill-equipped.

As OBGYNs, we are privileged to play a role in patients’ most intimate experiences, which are often rife with fear, hesitation, and humanity. Our practice ranges from management of suspicious masses to therapeutic abortion, from infertility to debilitating pelvic pain. We are also responsible for guiding conversations around life-limiting or life-threatening prenatal diagnoses.

Challenging experiences – including rare fetal malformations and the all too common early pregnancy loss – abound in women’s healthcare, and many of these experiences lead to varying degrees of worry and suffering on the part of our patients. The adoption of a palliative approach has the potential to transform obstetrics and gynecology to a patient-centered discipline rooted in compassion and informed by our patients’ values.

And yes, when occasional tragedies arise, we must also learn that in birth – as with death – not being able to fix a problem does not imply failure or inadequacy. Sometimes holding space for these tender moments is the only thing to do, and it can be so therapeutic.

Nathan Riley, MD, is an OBGYN and hospice physician with Hosparus Health in Louisville, KY. He also works remotely as a telehealth palliative care physician for Resolution Care.

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