Giving Bad News

[dagnastyUA]

We just had "giving bad news" in our medical interview class. It would be interesting to hear some stories from those who have had to do this... has anyone had to give bad news to an actual patient yet?

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[womansurg]

I copied this post from another website where I answered a similar question:

-ws

I think to this day, the most difficult news I have had to deliver was one event very early in my intern year. It must have been the first 2 weeks of my residency.

It was a weekend night, and we were taking level one traumas seemingly one right on top of another. My attending and the chief were in the OR with a gunshot victim; the junior resident was resuscitating an unstable motor vehicle collision patient; and I had been left to tuck a 15 year old boy - self inflicted, gunshot wound to the head - into the ICU until the family and the organ donor network arrived. We had already made a clinical determination of brain death.

The mother arrived, alone and frightened, having heard only that her son was injured in a shooting, but knowing nothing of the severity of his injuries or of the details.

I ran down to the OR to let my staff know about her arrival. The case in the OR was going poorly and both attending and chief were working feverishly to isolate and control bleeding.The wounded child upstairs had already experienced uncal herniation, and with his massive intracranial injury, was beginning to develop hemodynamic instability. My attending informed me that I would have inform the mother of the situation, and try to illicit permission for organ donation before the boy degenerated into irreversible shock.

I went back upstairs and brought the mother back into a conference room. I honestly can't even remember the words I chose or how I spoke them. I just remember the moment before I spoke, that nanosecond of intense hope in her face, how I was so loathe to proceed beyond that point. Then how injured she was by my words, and how inconsolable.

That same night, early in the morning hours, I sat and listened while my attending called parents in another state, awakening them from sleep to tell them that their 18 year old daughter had died shortly after arrival from the scene of a motor vehicle collision. She'd been one of several kids in one car, visiting a nearby college town for the weekend.

Too, too heartbreaking.

 

[Celiac Plexus]

Womansurg, that post is so powerful. Damn. I wish that I had some experience in that department, but the residents or attendings always give the "bad" news at my school.

I think that there should be a mandatory class at every medical school right before we graduate on "how to give bad news". I feel that there is not enough emphasis on training students to talk to family members...

 

[womansurg]

Thank you, Celiac Plexus. Those memories really haunt you...I still tear up if I dwell on them.

As a general surgeon, it's fairly common that I have to inform patients and families that the patient has cancer, and that it is inoperable or that their prognosis is otherwise poor.There's no question that my experiences with my dad's death from melenoma during medical school have made me much better able to understand and deal with the family's issues in these circumstances.

I've been told many times by patients and families that my communications were somehow easier for them to handle; they often say that I have left them with some hope, when other physicians left them feeling devastated. I am always completely honest, so it's not that I am concealing or distorting the truth. I've thought about it a lot - what the difference might be - and I think I can formulate at least some of it into concrete ideas. Excuse my presumption, there are lots of ways to do things, I know, but here is my way, if it helps:

1. Say it quickly. Usually they know and fear that the news is going to be bad. It's torture to sit there while someone banters about trying to find a way to speak the truth.

2. This is a big one, I think. Make THEIR problem YOUR problem. They need to feel that you are their ally. Instead of "it's possible that you have cancer. The final pathology will be back tomorrow", instead say, "I'm very worried that this might be cancer. We won't know for sure until the final pathology comes back, but I'm very concerned. I'm not going to sleep very well tonight, waiting for those results. I know you won't either." Let them see you sharing their fear and concern.

3. When someone is diagnosed with a terminal illness, their life is not over: rather, they (and their family) are beginning a new chapter. All of us have the story of our final days on Earth to live out. While the patient may be gone in a few months, the family is left with years and years of memories surrounding how that person's death unfolded. Help them to make this period a gracious and tolerable memory: worthy of the person who they have loved for so many years.

4. Everyone has some treatment options available, even if it is simply palliative care. Don't ever say, "there's nothing we can do". Instead say, "I can't offer you a cure, although I wish I could. The cancer has spread too far. But I CAN help you to live as long as possible, and as well as possible with this cancer. I'm going to have you meet with the oncologist/radiation-oncologist (whichever is appropriate). Their only job in the whole world is to help people with cancer to live longer and better - that's what they do."

5. People always want to know, "how long have I got, doc?" With cancer, especially, this can be tremedously variable. I always qualify answers, eg: "if I looked at a hundred people with this type of cancer, the average time that they live might be 18 months. However, in that hundred people there are some who might live ten years, and some who might only live a short time. Let's work on treating you and getting you as healthy as we can, so that you can live as long and as well as possible".

For what it's worth...

-ws

 

[SomeFakeName]

Womansurg, what do you think of the school of thought that says a doctor should never let a patient lose hope of being cured of a disease, even if the doctor knows that the patients will eventually die of the disease?

I realize that there is a premise for "false hope" in this view (as in you're giving the patient a false sense that he/she may overcome the illness), but it does still leave the patient with hope, which I believe is the most vital element a patient has if he/she is to go on actively living their life. For once their hope is gone, they virtually always become passively resigned to death and go through the motions of dying.

 

[womansurg]

Well, I've not heard of that school of thought in particular. I never tell people that they are going to die, without a doubt, but I do tell them - when they ask - exactly what I expect to happen based on my medical knowledge and previous experiences. I think it's very important to communicate at the level of what the person is ready to hear. They will let you know how much they are prepared to know. Also, it's a very different thing to hear, "I can't offer you a cure, but I can offer you treatment" than to hear, "you are going to die of your disease."

I think that battling for a 'cure' is very draining, very absorbing, and can be very illusory. Holding out that hope, and hanging all of your hopes and dreams on it is probably not a worthwhile use of your limited time and energies if it is truly the case that virtually no real chance of cure exists. So I wouldn't think that this would be very helpful.

Be it fair or unfair, it does often fall on the shoulders of we physicians to 'teach' our patients how to die - a task that many of us are ill equipped to perform. I certainly learned nothing of this in my formal training, and everything of this in my personal experiences as a family member of a terminally ill patient.

I think that we can help people realize that they are playing out a very important chapter in their lives when they are fortunate enough to have awareness of their impending death. When it's my turn, I hope I can conduct myself with grace and generousity and insight, and that the people I leave behind are left with precious memories of that time. That is a REAL realizable goal for terminally ill people, and one that we can often help with.

 

[S.c. Cdc28p]

Thanks for sharing these extremely insightful thoughts, womansurg.

 

[Diogenes]

I'd like to add something. When you give bad news, don't be so selfish as to focus on how giving bad news makes you feel. This isn't about you. It's about them. Be sympathetic of course, but don't feel sorry for yourself or be upset or agitated because the situation makes you uncomfortable. Suck it up and focus on the patient and their family and how it makes them feel and what they need.

 

[Annette]

From personal experiences, I'd like to add to the above guidelines:
1) make certain that you have as much information about the disease/ prognosis/ treatments etc. when you go to talk to the patient and or family.
2)Be prepared to spend time with them.
3)Talk in a private, quiet place where they can stay for awhile.
4)SIT DOWN.
5)Realize that they may "forget" all of what you have said. If you need to give them alot of information all at once, tape record the conversation for them, or give them notes. If you will be seeing the patient or family again soon, let them know that they can talk to you again, and ask questions.

 

[dagnastyUA]

CP-- Why in the world would you want to give bad news in "real life" so-to-speak?

Originally posted by Celiac Plexus
Womansurg, that post is so powerful. Damn. I wish that I had some experience in that department, but the residents or attendings always give the "bad" news at my school.

I think that there should be a mandatory class at every medical school right before we graduate on "how to give bad news". I feel that there is not enough emphasis on training students to talk to family members...

 

[dire tribe]

Those of you interested in this thread might also be interested in this article that appeared in the New Yorker about how doctors should give bad news.

http://www.newyorker.com/fact/content/?021028fa_fact

 

[Yogi Bear]

Originally posted by dire tribe
Those of you interested in this thread might also be interested in this article that appeared in the New Yorker about how doctors should give bad news.

http://www.newyorker.com/fact/content/?021028fa_fact

great article! thanks!