Views And Reviews Acute Perspective

David Oliver: No more broken promises

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4855 (Published 09 September 2016) Cite this as: BMJ 2016;354:i4855
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}googlemail.com

In clinical practice, trust is paramount. We trust team mates to know their job and to hand over well. Patients and families need to trust that we’re competent, compassionate, and acting in good faith.

But sometimes, in trying to reassure patients and with the best of intentions, we make promises we shouldn’t. And broken promises damage trust and confidence.

Some promises concern what we as individuals or teams will do for patients. For example, “We’ll do our best to get you as well and as close to your usual abilities as we can.” “We will refer you for this test or to that team.”

Expert, evidenced, or educated prognostications about how much better or worse a patient might get or what a test or treatment might achieve—these are, partly, promises: “This treatment might improve your pain control and help your mobility, but in your case there’s only a 50/50 chance.”

Careless talk may not cost lives, but it causes real problems

Benign sounding phrases such as, “We’ll have you back on your feet in no time” or “We’ll have you home in a day or two” can cause disappointment. Or, sometimes pushed by patients and families, we promise exact discharge dates or how many days’ life are left. Definite assurances may well cause problems for colleagues who have to reverse the expectation, so they’re best avoided.

Then there are promises none of us should ever make: those on behalf of other practitioners or services we don’t work in and perhaps don’t fully understand. “We’re sending you up to the medical assessment unit—they’ll do a scan and get you straight home.” “They’ll admit you to hospital for a few days.” “Go and see your GP when you get home, and she’ll sort out your blood pressure.” Or, “The social worker will organise some home care for you this week.”

We should never make promises not in our gift, on behalf of others. It’s unfair on colleagues, patients, and families—so it’s unprofessional.

Managing expectations is critical. “We’ll refer you to the community hospital but it might take a week for a bed to come up, and you might be well enough to go home before then.” Or, “Your dad will have to leave intensive care/the stroke unit for a general ward soon, because these beds are scarce and he’s stable enough. They don’t have the same nursing and therapy levels as we do, and specialist rehabilitation beds are under a lot of pressure.”

There’s already enough misunderstanding, even when experienced clinicians carefully choose and properly communicate their words, without further complication. Careless talk may not cost lives, but it causes real problems.

Don’t make promises you can’t keep. It’s less disappointing in the long run to under-promise but over-deliver.

Footnotes

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