“I Wish Things Were Different”: Expressing Wishes in Response to Loss, Futility, and Unrealistic Hopes

• Physician-patient relations
• Physician role
• Empathy
• Knowledge, attitudes, practice
• Attitude to death

Physicians who care for patients encounter many powerful and painful emotions, including anger, sadness, fear, grief, loss, hopelessness, and blame. Many studies suggest that physicians should express empathy in response to emotion-laden patient statements to ensure that patients feel listened to and understood. These physician responses usually consist of efforts to comprehend how things feel to the patient and to express that understanding back to the patient (1–8).

Situations that evoke loss, guilt, or hopelessness are particularly hard for physicians to respond to empathically. Physicians who think that they have failed a dying patient and who fear depriving the patient of hope may respond by avoiding the topic entirely, by overcompensating with overtreatment, or by apologizing for not “saving” the patient. When a patient expresses overwhelming anger or disappointment with limitations in medicine, physicians may be afraid that any explicit response to the patient's emotion may be construed as evidence of their failure, mistake, or inadequacy.

In these challenging situations, we have observed that many physicians attempt to respond empathically by stating “I'm sorry.” This well-intentioned response, although frequently appropriate, may be misinterpreted and misdirected. We have found that saying “I wish … (things were different)” to the patient and family is a more effective initial response. We explicate some of the challenges of saying “I'm sorry” and explore the potential benefits of joining with patients and families and saying “I wish …” in specific, difficult clinical scenarios.