COMMENTARY

Doctors Must Give Life-or-Death News in Person, Not by Telemedicine

Arthur L. Caplan, PhD

Disclosures

April 01, 2019

This transcript has been edited for clarity.

Hi. I'm Art Caplan. I'm the head of the Division of Medical Ethics at the NYU School of Medicine.

A patient in the Kaiser Hospital in Fremont, California, was 78 years old, had severe lung disease, had been admitted three times, and was clearly terminally ill. I think his daughter and the doctors treating him knew that.

However, for some reason, during his third admission, a robot bearing a video screen entered the room to the amazement, I think, of both the patient and the doctor—they hadn't been expecting this.

A discussion took place with a physician—although I don't know the specialty or where the doctor was actually located—in which this doctor said he did not think that the patient was going to go home, and that they needed to think about managing pain control and moving to comfort care. When the daughter asked if hospice was possible, he said he didn't think so.

They had a very detailed end-of-life discussion, but it was by television and delivered by a mobile robot. I'm not against telemedicine—I've said that before on other opinion pieces I've presented to you—but this seemed to me to be an utter ethical disaster.

The patient was hard of hearing and he couldn't really follow what the video was transmitting. The daughter was trying to translate what the doctor on the video screen was saying, but she was learning bad news for the first time and was emotionally distraught. Both the daughter and the patient expected to have a personal visit, not something done remotely by video.

It still is unclear to me why Kaiser decided to introduce this robot-borne video telemedicine approach. Were they short on doctors? Was somebody out sick? Whatever the case, the presumption has to be that we're not going to use—particularly in emotionally charged situations like end-of-life care—impersonal presentations by video. The presumption is that we will try to have face-to-face encounters.

In almost every culture in the United States, people expect to have personal contact with a doctor [or] if they want a chaplain, a social worker, or nursing involved. The team, I think, has to be there. Interpersonal contact is a key element of empathetic, patient-first care. You can't just roll in the robot-borne TV screen and expect that many patients and family members are going to be comfortable with that, which leads to the core point.

I have said that the presumption is that it will be personal. If you seek consent and educate patients that you may have to use doctors at remote locations—maybe you're in a rural area, maybe you're in a small hospital that doesn't have the right specialist to handle certain questions—well, fine. Informed consent to the use of telemedicine, I think, is just essential.

As telemedicine appears more and more in healthcare, we should be sure that patients, family members, and those who are speaking for them are comfortable with that technology. We can use telemedicine, we should use telemedicine, and I know many of you watching probably have been in situations where there were telemedicine consultations or somebody spoke with the patient from afar.

However, we must get informed consent. We must make sure that we don't come to rely on that as the standard of care. Telemedicine should be the exception, not the rule, when we get into situations like end-of-life care.

Having a patient and a daughter feel despondent and terrified, learning about the imminent death of the dad, is no time to deliver news unexpectedly by a robot-borne video screen. That's not the way to move medicine forward to show empathy and respect for our patients.

We have to do better. And I think we can, but let's learn from this mistake.

I'm Art Caplan at the NYU School of Medicine. Thank you for watching.

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