Breaking Bad News

[Luba Licious]

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What kind of bad news do you break to your patients as a student? Are you expected to tell someone they're terminal, or is that up to the resident/attending? I can see a student breaking some minor bad news, but I think terminal diagnoses should be left to someone higher on the food chain. Thoughts?

 

[Droopy Snoopy]

What kind of bad news do you break to your patients as a student? Are you expected to tell someone they're terminal, or is that up to the resident/attending? I can see a student breaking some minor bad news, but I think terminal diagnoses should be left to someone higher on the food chain. Thoughts?

I try to be as general as possible, and even that only when asked directly when pre-rounding or something and only when I know something for certain. I would never presume to tell a loved one their family member has passed, or that grandpa is likely never to wake up from that massive stroke. That's attending-level stuff -- his patients, his license, and ultimately his a** if there's a miscommunication.

We are expected to learn how to do this via observation, not kicked out of the room or anything. We even had a lecture on it M2 year.

 

[anon-y-mouse]

Obviously, students never break that kind of information, so this is kind of an irrelevant question. Perhaps the senior resident or attending would do so, after a discussion with the attending of course, depending on how involved in patient care the attending is. If someone asks me about some STD result or anything like that... if it's negative and depending on the situation, I tell them, and alleviate their concern that way. If it's positive, I usually say that I don't have the information on me, and that it's in the computer somewhere. Always blame the computer. It's much better than being like "I'm sorry, I can't tell you", which is a LOT more disconcerting/nerve racking to a patient who then has to WAIT. The diagnosis of terminal / options for withdrawing support / etc. are all attending-level things in general.

 

[LadyWolverine]

I called a couple of the patients that I saw while on family med to inform them that they had an STD and that they and their partners would need treatment. It wasn't really a big deal - my preceptor asked if I felt comfortable doing it before turning it over to me, and it ended up letting her attend to more pressing matters in clinic. Not really super-heavy stuff, though (like, for instance, telling a patient that he/she has a terminal illness or very serious or incurable disease).

My first year, I volunteered with a palliative care consult service, and sat in on family meetings where bad news was broken to families (typically by the surgeon or the attending IM doc, with a social worker there as a support and to field non-medical questions). Eventually I became comfortable enough with those types of situations to join in the ensuing discussion, although it was never my place to actually "break the bad news."

Now that I am a 3rd year, the situations are similar - I am not the bearer of bad news (this is still typically either the senior resident or the attending on the service), but I feel much more confident partipating in discussions about life support withdrawal, end-of-life care, hospice, pastoral care, patient and family fears and concerns about death and dying, dealing with very emotionally distraught people, etc. It's not dropping the actual bomb itself, so to speak, but I think this experience will prepare me to assume that role with relative comfort in the future.

If you are interested in gaining some experience with professionally and compassionately breaking bad news to your patients (a necessary ability for pretty much any type of doctor, with the exception of maybe a pathologist 🙂), it might be worth it to shadow the palliative care service at your local hospital or volunteer at a hospice, where you can participate in family meetings and talk to dying patients about their experiences. Another option would be to spend some time in the ICU, where there are family meetings and bad news being broken on a regular basis.

I think it's important to become familiar with this stuff early on. You are going to have very sick patients on your 3rd year rotations who will get sicker/code/die while they are under your team's care - oftentimes, you will know the patients and/or their families very well, because you (as the medical student) will be spending the most time collecting information for your H&P, being very thorough, just spending time talking to the family, etc. As you are typically their closest point-of-contact at the hospital, it's nice to be able to help them through the difficult times and decisions that they will have to face. Of course, you should always respect your boundaries as a student, but even as an MS3 you can be a whole lot more involved than just deferring to your attending or resident all the time.

 

[Luba Licious]

My attending wanted me to tell a patient that they had terminal cancer. When I balked, he told me that I would soon be a doctor and need to be able to do this. I thought it was a little beyond the scope of what a 3rd year should be able to do, and didn't really understand why he was so adamant about it. I refused to do it, however, and am glad because I didn't know much about the disease, next steps, is treatment even a good idea, etc. Just wondering how it was in other institutions. I do give minor bad news, but thought it was too much to tell someone they were terminal when the poor patient had NO IDEA.

Thanks for your input. 🙂

 

[Droopy Snoopy]

My attending wanted me to tell a patient that they had terminal cancer. When I balked, he told me that I would soon be a doctor and need to be able to do this. I thought it was a little beyond the scope of what a 3rd year should be able to do, and didn't really understand why he was so adamant about it. I refused to do it, however, and am glad because I didn't know much about the disease, next steps, is treatment even a good idea, etc. Just wondering how it was in other institutions. I do give minor bad news, but thought it was too much to tell someone they were terminal when the poor patient had NO IDEA.

Thanks for your input. 🙂

I think your attending was a little out of line asking you, but ask you he did. It's interesting that you refused, think I would've scrambled onto uptodate and looked up as much info as possible and trooped on in there.

 

[FutureInternist]

The worst I had to do was to talk to a patient's family about taking the patient off of life-support. I went through the whole thing w/ first the resident, then the attending & then finally went & talked to the family w/ the attending there the whole time.
My case might have been a little different since this patient was in the ICU for the whole of my rotation so I was pretty comfortable w/ the family by this time.

 

[anon-y-mouse]

My attending wanted me to tell a patient that they had terminal cancer. When I balked, he told me that I would soon be a doctor and need to be able to do this. I thought it was a little beyond the scope of what a 3rd year should be able to do, and didn't really understand why he was so adamant about it. I refused to do it, however, and am glad because I didn't know much about the disease, next steps, is treatment even a good idea, etc. Just wondering how it was in other institutions. I do give minor bad news, but thought it was too much to tell someone they were terminal when the poor patient had NO IDEA.

Thanks for your input. 🙂

You should have told him what your concerns were, and that you'd do it if he'd walk you through it first. One of my attendings asked me do almost an entire hernia repair- I explained my concerns, and he walked me through everything step-by-step. I had the option of backing out and handing him the instruments at any time. A little different, but we are often put in high pressure situations like these, and that's why we have a lot of upper-level backup -- I think we should capitalize on them and constantly test our limits (provided the checks+balance are in place).

 

[smq123]

Sometimes these "bad news" conversations aren't planned - I find those the hardest to handle.

On gyn-onc, I was pre-rounding one morning when one of my patients started crying and telling me about how she didn't want to die, wanted to see her grandkids grow up, etc. It wasn't really a situation where I could just be like - "well, the attending will be by later and she'll talk about all your options with you, see you later"

Last week a family member approached me in the hall because she wanted to know "how bad it really was" and whether the patient was making the right choice by being DNR.

These are not "bad news" conversations. I think you're getting yourself confused.

There are some uncomfortable conversations that actually have nothing to do with whether or not you are part of the healthcare team. The conversation you had with your gyn onc patient was one of those. They don't REALLY care about their prognosis, treatment plans, etc. - they're just scared and want someone to comfort them. You don't need a medical degree to be able to do that.

The second conversation tends to be one of those thinly veiled "What would you do in my shoes" conversations. Whatever you do, don't let yourself get sucked into one of those. It never ends well. Because, really, you CAN'T put yourself in their shoes. Even if you did have experience with a relative that you eventually declared DNR, it doesn't mean that your experience will mirror the experience of your patient.

I have tried to listen in on as many "bad news" conversations as I can, to try and pick up style points from the attendings on what to do and what not to do. But man, I still feel clueless the whole time when I get stuck in situations like above. I think admitting when you don't know something or don't have a good answer helps - as long as you then go look up that answer and come back later to follow-up.

Like I said, those conversations that you described aren't really "bad news" conversations.

Looking up the answer and "coming back later to follow-up" is kind of useless. The moment has passed, and it doesn't make the patient feel any better.

And "looking up the answer" is such a standard medical student knee-jerk response to any uncomfortable situation that it's kind of funny. Most of the questions that your patients are REALLY asking don't have answers - "How much time do I have? How much pain will I be in? Could I have caught this earlier? Were there warning signs that I missed?" Those answers aren't in UpToDate or in the Washington Manual. Some questions just don't have any answers.

 

[smq123]

Obviously, students never break that kind of information, so this is kind of an irrelevant question.

"Never"?

I've had to. A couple of times. Once, the intern told me to go in and talk to a woman who had no idea that she had an inoperable GI cancer. Other times, I've been the first to see a patient in triage and have picked up on an alarming physical exam finding. While that doesn't quite "break" the bad news to them, the fact that you're worried makes them worry. You can't just walk away and say "Well, I'm getting the resident" - you have to give them an inkling about why you look a little worried.

Also had to break some pretty sad news during infertility clinic. 🙁

And once I definitely did have to break bad news, because the attending didn't speak the same language as the patient, and I did. So by translating what the attending had said, I became the bearer of bad news. That was pretty bad.

My attending wanted me to tell a patient that they had terminal cancer. When I balked, he told me that I would soon be a doctor and need to be able to do this. I thought it was a little beyond the scope of what a 3rd year should be able to do, and didn't really understand why he was so adamant about it.

While I don't agree that breaking bad news is "never" the responsibility of the med student, what your attending tried to do is pretty $hitty.

That's highly disrespectful to the patient to have the most junior member of the team break the news of a terminal diagnosis. It's like the story I heard about how the resident made the high-school aged candy-striper tell a family that its newly born child had Down's syndrome. 😡 WTF?!?

 

[smq123]

I know "looking up the answer" is a cliched response - but if you actually do it, patients sometimes appreciate it. Obviously there are tons of big picture questions that don't have a good answer, but sometimes there are specific things that can easily be answered, and I just don't happen to know what that answer is.

I know. I've had to do it, too.

While I see what you're saying, what I think that patients appreciate is the effort that you went to in order to answer their question. Sometimes I think that the answer itself matters less than the fact that you were thinking about them, and had actually been listening to them.

And I do kind of stretch the definition of a "bad news" convo to more than just new prognosis/diagnosis, I'll admit. I tend to lump all these emotional conversations that I'm uncomfortable with/feel unprepared for together, and try to learn how to get better at them by listening to others wade their way through them.

I think that, in a way, breaking bad news is easier. You can prepare yourself for that, to an extent. It's a conversation that you know in advance is going to happen.

The emotional conversations are harder because, even though they take less medical training to understand, they come out of nowhere. You can't really prepare yourself for them, and they can sometimes blindside you.

 

[Tiger26]

At least you guys seem to have a lot more common sense/compassion than the guy in the class ahead of us who told a woman that her baby was dead when he couldn't hear the fetal heart tones.

Apparently there was a lot of baby mama drama, especially when the resident walked in and found that there was, in fact, normal fetal heart tones . . . .

 

[PeepshowJohnny]

At least you guys seem to have a lot more common sense/compassion than the guy in the class ahead of us who told a woman that her baby was dead when he couldn't hear the fetal heart tones.

Apparently there was a lot of baby mama drama, especially when the resident walked in and found that there was, in fact, normal fetal heart tones . . . .

Oh God, I hated OB Clinic for that reason.

Twice I couldn't find the fetal heart tones with the doppler. Both times neither could the resident (after I left to go and get him) and we had to go get an ultrasound. Both kids were okay.

It freaked the hell out of the parents, even though I was playing it cool.

 

[OneFellSwoop]

I'm an MS3 and I just broke my first cancer news to a patient this morning during surgery rounds. Fortunately, my attending and I had the conversation with the family right after the surgery, but there is a strange social situation and they didn't stay with or tell the patient last night the results. When the patient asked me this morning while I was rounding I basically regurgitated what my attending had said the night before. Still, it was quite an experience to look the patient in the eye and discuss this with him. Oddly, he wasn't overly shocked, but he also never thought it was malignant, despite the fact that he has a 75 pack-year history and a growing mass in his lung that he's been sitting on for about a year. Anyway, weird emotions with this case, and now I have the shelf in the morning, what an interesting end to Surgery!

By the way, I was pretty worried about what my attending would say when I told him that I told the patient, but he wasn't mad at all, in fact, he was like "good, the patient has a right to know his condition, and you had an opportunity to break bad news." My surgery attending is pretty chill, so I imagine there could be some that would be ticked. I too had heard that as a med student, we shouldn't give bad news, but sometimes you just have to go for it and take a chance.

 

[45408]

No, I've never broken really bad news, but I try to get myself into the room when it's being talked about. The worst was definitely waking a patient up in the PACU and telling him that he was going to die in <48 hours (massive ischemic gut - he actually died within 5 hours). That was pretty disheartening.

I did get taken aside by a patient's family in the cafeteria. We'd just finished an operation with a similar very serious situation, and I thought she had a good chance of making it, so I tried to be positive with the family (but not give out too much info, because I wasn't sure what all the attending had said). Unfortunately, she died too...the odd part about that one is that I actually broke the news to the surgeon who operated on her that she died (like 18 hours before!). She was in the SICU, so she was under someone else's care, but nobody had thought to tell the surgeon!