Knowing when to step back 

By Victor Lopez, MD, Centro Cardiovascular SM, San José, Costa Rica & M. Carolina Musri, MD, Johns Hopkins Medicine

As an observer in the Hospital Medicine Observership Program at Johns Hopkins, I’ve had the opportunity to immerse myself in the complexities of the U.S. healthcare system. This experience has emphasized the structured approach to patient care, including practices that differ from those in my home country—particularly the discussion of code status with patients, which is neither common nor routine back home in Costa Rica. My initial surprise at these conversations quickly turned into understanding as I witnessed firsthand how essential they are in delivering patient-centered care. 

A patient arrived, Mr. B, and during admission the code status was discussed and the patient indicated he wanted a DNR. However, Mr. B then later decided he wanted to speak with the physician again to review this decision and was feeling quite anxious about it. 

In Costa Rica, we don’t routinely ask patients about their code status as part of the admission process. Instead, these discussions are reserved for very select patients in specific circumstances and it’s not a standard practice. This is one of the major differences I observed between the approaches in the U.S. and Costa Rica. 

I watched and listened as Mr. B grappled with a discussion about his code status order. He seemed confused and frightened. Mr. B wanted reassurance that if something were to go wrong, he would receive every possible intervention to “bring him back,” but he was adamant about not wanting to be kept alive on a machine “like a vegetable.” 

Dr. G calmly guided the conversation. He acknowledged the patient’s anxiety, validated his feelings, and said it was completely normal to feel overwhelmed by this kind of discussion. Dr. G then explained the process of resuscitation in simple—yet comprehensive—terms, describing the role of chest compressions and the possibility of a temporary need for a breathing tube. But despite Dr. G’s best efforts, it was clear that the patient remained distressed. Recognizing this, Dr. G suggested they revisit the conversation the next morning, giving the patient time to reflect and ask further questions. 

Here are four things I learned from this experience:  

1. Express empathy. 

Work to understand the patient’s feelings and concerns. Validating emotions helps them feel valued and supported and can ease anxiety.  

2. Listen first, speak second.  

By focusing on the patient’s words and concerns, you build trust and ensure their worries are fully addressed. 

3. Know when to step back. 

Recognize when a patient needs time to process information. Sometimes, stepping back and allowing them time to reflect can lead to better decision-making and a more comfortable resolution later. 

4. Make yourself available. 

Clearly communicate your willingness to re-engage when the patient is ready. Make sure they understand they can always reach out any time with questions and concerns. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.