Wednesday, July 3, 2013

Delivering Bad News

Even as a student, I realized that it was important to deliver bad news honestly but with a bit of hope, if at all possible. I watched my mentors. Some did this well, some poorly. I tried to emulate those who did it well. As my career progressed, I became more comfortable with delivering bad news to patients and families, whether it was the family of the brain dead trauma patient or the newly diagnosed brain tumor patient. Clearly, these were very different situations and I realized that my approach differed in the two situations.

First, in the case of the unexpected, irreversible situation, I don't think a brief encounter is adequate. It is just too much for someone to process. It seems that it takes about three encounters to get the family to the stage when they can actually process the news.  The first usually involves discussing the severity of the injury and poor prognosis. The second involves a reexamination and discussion of the likely irreversibility and the plan for further evaluation. The third also involves reexamination and giving the results of the further evaluation. In the case of brain death, this is when I say the patient is "dead." Most people don't understand the term "brain dead" so I try to avoid using it. It is at this time that I bring up the discussion of "what comes next." I try to arrange to have the chaplain or social worker there for this discussion. In the case of brain death, I also like to arrange to have the organ procurement personnel available, so that I can introduce them once the family has had a bit of time with their feelings, with a support person if desired. In this way, the "hope" can be the opportunity to give another the chance to live, since unfortunately this is not possible for the patient.

The case of cancer is much different, in that sometimes the discussion takes place in an outpatient setting, but rarely on a one encounter basis. First, the patient learns there is something wrong, then gets a scan, then usually has a surgery, then gets the results of the pathology. Similar to the trauma situation, this series of discussion helps to prepare the patient and family to hear the news. But, still, there has to be some hope, here in terms of suggesting treatments that make offer some chance at quality, even if there is limited potential of prolonging life.  

I think my early sensitivity was because of seeing how my mother was initially affected when she was told that she had breast cancer. She was initially destroyed, but then came to realize that she still had a life to live. She died years later of unrelated causes while traveling. Her cancer had remained under good control throughout. I also observed others with cancer who kept going and even took on new projects such as remodeling a home or taking on a new career, and continue to do well many years out. It seemed important to encourage this focus on continuing to live, not preparing to die. There had to be the flicker of hope in the midst of the bad news lest the patient fall into despair.

Any of these discussions take time. Sometimes, it's just necessary to be available while the family processes the information. But, other times, the discussion itself can be more lengthy. Simply delivering the news and leaving may devastate the patient or family. They may not know what happens next and so it is helpful to offer some guidance, even if it is limited.

And, in my experience, touch is very important. Not the impersonal, clinical touch of an examination, but a gentle hand or even a hug might be appropriate, and reassuring that, even in the absence of being able to offer a medical solution to the problem, the physician will be available in a human, caring way. As physicians, we have been taught to be objective, but distancing ourselves at this point may serve more to protect our feelings than to help the patient. Even shedding a tear with the patient and family will show that the physician cares, and they have often been appreciative in my experience.

My experiences as a patient being given bad news have at times left me in tears, while at other times given me hope for the future. The sense of caring and hope which I have at times been given make me want to go forward. Even more than the details of the news being delivered. I don't think it is false hope, but rather motivation to survive.