Delivering bad news

[REWahoo]

I want to apologize in advance. Since seeing this thread earlier today I've been resisting the temptation to post the following textbook example on how to give bad news. Unfortunately I've lost my self control...

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A man left his cat with his brother while he went on vacation for a week. When he came back, he called his brother to see when he could pick up his cat. The brother hesitated, then said, "I'm so sorry, but while you were away, your cat died."

The man was very upset and yelled, "You know, you could have broken the news to me better than that. When I called today, you could have said he was on the roof and wouldn't come down. Then when I called the next day, you could have said that he had fallen off and the vet was working on patching him up. Then when I called the third day, you could have said he had passed away."

The brother thought about it and apologized.

"So how's Mom?" asked the man.

"She's on the roof and won't come down."

 

[W2R]

"She's on the roof and won't come down."

I might well say that. The older I get, the less tolerance I have for obfuscation and delay. Just cut to the chase. Then we can talk about options.

This brings up an issue. Some people just [-]do not[/-] will not hear the facts when the doctor starts saying dire things. Their minds just completely shut off, in terror. In a situation like that, it is sometimes best to have the spouse or nearest relative there too, to listen and take notes. Otherwise, when the patient gets home he/she may not be clear at all on what the doctor said.

 

[urn2bfree]

There are a number of books on this subject. My personal favorite is How to Break Bad News by Robert Buckman He gives one of the most entertaining lectures on this topic or any topic

 

[Tractor guy]

I've not had to give bad personal news but I have had to give bad business news to various audiences (eg your product isn't ready to go to production, we need to delay 6 months) These were high stress meetings because we were talking $M/week of delay.

I was taught and practiced that important points need to be stated 3 times in a presentation.
1) Start the presentation with a summary of what you want the person you're talking to to remember. Ideally this is written down because most people remember what they read better than what they hear.
2) Go into the details. Because your audience has seen the summary, they can better understand how these details support the conclusion. They'll be in a position to ask appropriate questions.
3) Repeat the summary.

This is the prepared part of the presentation. A good presenter will listen to their audience and deviate from his prepared presentation if part of it isn't being understood.

If I was in a doc's office I would want him to communicate with me the same way.

Lorne

 

[Ally]

I may be an oddity here. I would like to be told in a compassionate straight forward way. I have had two doctors offer to pray for me and my condition, and I liked that. But I can imagine some patients not liking that much at all. However, in West Tx, people often offer to pray for each other over even small issues. One of my coworkers got breast cancer a few years ago, and I told her I would pray for her. She said "please don't!" it turns out that she is an atheist and was offended by people saying that to her.

 

[FreeAtLast]

About 30 years ago we had a infant son premature never left the hospital and after 4 months it was clear to the doctor that he was not going to make it. The doctor told us that he had a 0% chance of survival, and then went on to answer our questions in a very compassionate manner. He had been giving us updates almost every week for several months, however, that was the final one. My son passed 2 weeks later.

When my wife died about 10 years ago the doctor told her about the illness that she had and said that it was treatable but there was no cure. If thing went well she might have 5 years. After the doctor left she said I'm scr*wed, I remained hopeful she would have the 5 years. She passed 2 weeks later.

I much prefer option #1 as we were told that there was 0% chance and what we really were facing in the near future.

 

[Sandhog]

I had liver cancer and liked the way my doctor, Oncologist, said to me.

Me: How ya doin' doc?

Doc: Better than you, Sam. You have a liver cancer. Your liver profile show positive signs for cancer but we'll not for sure until after biopsy.

Me: (Shock and disbelieved that I have a liver cancer) What are my options?

Doc: Let's get biopsy and start you on the chemotherapy and put you on the liver transplant national registry.

I forever grateful to my doctor for telling me straight forward instead of worrying about my feelings. This was back in November 1, 1999. I'll always remember the date cause I heard on the radio that Walter Payton die of liver cancer. I remembered feeling sorry for myself but was glad my doctor took swift action rather than trying to comfort me.

 

[obgyn65]

Being a clinician myself, I always try to deliver bad news in a very gentle manner. Michelle - I would not rely on the answers given under this thread to change your style of news delivery to your patients.

The breaking-the-news-slowly technique can go on for 5 minutes before I get to the crux of the matter, and I've often wondered if it might not be better to break such news more quickly.

 

[chemist]

Having had 4 cancers in my short lifetime, I am thinking back to how I was told/found out about each.

I think the first was the worst - I had Hodgkin's lymphoma (didn't know it), lost 20 pounds in a month and had night sweats and passing out. Drove myself to the ER!? where the doc ordered a chest xray. Sitting on a cot with the curtain partially drawn I saw the doc who had called over two other docs looking at my xray on the light box. They were all shaking their heads and I heard one say something ending in "oma". I was actually relieved because this was back in the early days of HIV/AIDS and I was single at the time.

When I had malignant melanoma my dermatologist just matter of factly said when I came back to have sutures removed, "We're going to keep an eye on this site, it came back as melanoma". Called my oncologist where we determined said 70 year old dermatologist was a quack and had a second surgery to remove wide margins.

Last two cancers were just basal cell carcinomas. Dermatological oncologist called me and delivered the news in both cases second surgery required beyond the biopsy.

I think a brief to-the-point diagnosis followed by prognosis / forward plan is the way to go. I don't need to hear the pathologists report. Plenty of time to discuss cell type etc later - need to digest the big picture first.

 

[rescueme]

The older I get, the less tolerance I have for obfuscation and delay. Just cut to the chase. Then we can talk about options.

I'm with you.

Let me know the "mile marker" I'm at, and a guesstimate of when I will run out of road.

Heck, everybody dies. For me, the most important thing is to get my family "situated" before I go, and insure their further requirements in life.

It might be that I've been exposed to death (family and otherwise) at an earlier age than most, and I understand that plans need to be made/confirmed for the living - not to worry so much for the "rose" (me ) who is "dying on the vine".

Additionally, in our case, having a disabled child (adult), we've made plans for his continued existance after we're gone, so we've lived with the fact of us not being around for many decades, and have faced our own mortality earlier than most due to that challange and had to make end-of-life decisions earliler than most.

My time is past (or soon to be). Give me the info that will allow me to wrap up plans for those that I leave behind...

 

[Bestwifeever]

I know in my parents' generation (born in the early 1920s), bad health news often was kept from the patient and shared only with the family who then could decide whether or how to break it to the patient. Maybe people are more realistic today about death and prognosises (prognosi?). Also we are relating how we would like to be told, at our current age, when we anticipate not always hearing "the test were fine" and most of us are pretty darned good at googling whatever we've been tested for. You would probably get completely different answers on a "young parents' forum," for example.

 

[Texas Proud]

+1 on getting to the point....


IOW, I would rather hear that bad news quickly so I don't have to sit thinking about what it is that I might or might not have...

First, we know something is up since docs today don't spend that much time with patients... also, calling to set up an appointment to 'discuss the tests' can only mean bad news.... if there were not bad news I would already know the results...

I had one woman who worked for me and she had tests done... got a call to meet her doc to 'discuss her tests'.... she hung up and said 'I'm screwed and I don't know what it is....' she died less than 6 months later.... the bad thing IMO was she had to wait 3 days to get in with the doc... If you have bad news and want to meet, at least make the time that day to tell us....

 

[utrecht]

I generally deliver such information (I've done it a lot) using direct and basic information that I think is essential for the patient to know. Then I offer my empathy and sympathy, sit back and listen and watch. The patient drives further information by asking for it directly ("so show long do I have?") or indirectly ("that doesn't sound good...").

This is a very intricate dance and family is often involved. Patients usually don't need protection from the truth (notwithstanding family opinion to the contrary), they just need good information, a ton of kindness and dignity. There is a tendency to want to say too much at the first meeting, and I usually told my students to err on the side of listening - you can always go back again.

Of course in the real world it is a much messier affair with some combination of sadness, anger, denial, family involvement, etc etc. I don't know the OP's role, but this kind of learning is best acquired using both didactic sources (classes and lectures) as well as intense mentoring with senior faculty or colleagues.

Feel free to PM me if you wish. I am a retired academic internist/hospitalist last sighted at a large tertiary cancer center, with 25 years preceding that doing primary care.

Coming from someone who just went through this exact thing less than 2 weeks ago, I can say that Rich has it 100% exactly right. My mothers doctor did almost exactly what Rich just described and I dont think it could've been handled one iota better.

I do think I would avoid using the words "I have bad news". Just say it. They will know its bad news and it doesnt need to be announced in advance like they do on TV.

When I say "just say it", I dont mean right up front. I mean describe how sick the person is, that everything has been done that can be done and then advise them that the patient will not survive with as much empathy as possible. Also, I think it is good if you are uncomfortable delivering the news. If its easy for you it will come off as callous and uncaring.

Lastly, I think you should do it when you can plan in advance to not have anything else pressing to do for at least 20 minutes. I think the doctor should stay in the room answering questions until the conversation naturally comes to an end, then say something like "I'll leave you to process all of this. Let me know if you have any more questions". Dont leave and cut off the conversation because you have something else to do.

 

[spirit]

Thank you all for your heartfelt responses

12 years ago my mother informed us that she probably had had a stroke. Her speech pattern at a visit to her dentist, prompted him to recommend her to get medical advice. This was in Feb and by May her condition worsened. Just when she stabalized, her symptoms changed and it seemed her family was on a rollercoaster of responses. A Cat scan did not show any conclusive evidence otherwuse and so she continued to be treated as a stroke patient. She was being admitted and released constantly from a rehabilitative hospital which was very draining on her and us. The brunt of the responsibility fell on my 80 year old father and it was a difficult time since she wandered at night and he got very little rest. However, I do remember the kindness and caring from her whole medical team.
While at home she had a seizure, was admitted to hospital and while there managed to have a MRI done.
I'll never forget the resident at the hospital. I called him from work early in the morning and he gently but quickly ran by me his rationale for ordering a MRI. "Your mom is not a stroke victim, her symptoms keep worsening. In my experience a stroke patient is in need of serious treatment immediately, slowly recovers and goes home. They do not slowly get worse. I am ordering a MRI and should have the results later today" (This is my layperson translation of his words )
That night I went to the hospital and he told me my mother had an inoperative brain tumor and needed to be told to be able to put her affairs in order. I did not think I had the ability to tell her the news or my father either. He told me that he believed it was the right of the patient to know their medical condition and in the past family made the decision to either inform the patient or not. Today, he could not ethically do that and if we would or could not tell her then he would. He also believed that most patients already know there is something seriously wrong and appreciate the dignity of being allowed to deal with their illness on their terms.
I am forever grateful he gave me the opportunity to take my mother's hand, look her in the eye and with compassion tell her we all loved her but I had some bad news to give her. Her response was so loving and kind. She told me she had had a good life, lived with people who loved her all her life and watched her children and grandchildren grow up. She was at peace with her life and was ready for the next phase of it.
I will always remember that resident and am grateful he allowed me to have that wonderful moment with a woman I loved very much. Thank you all for your great responses. Today is Canadian Thanksgiving and I am grateful for all the wise and caring people who selflessly give of themselves here on this forum.

 

[DangerMouse]

I had some tests done this morning and am waiting for results.

If it should be something serious such as cancer, I am hoping my Dr delivers the news over the phone in a factual method so I can process the info rather than having to receive the initial news face to face which will result in me blubbering any not gaining anything useful from the visit.

 

[Sarah in SC]

I had some tests done this morning and am waiting for results.

If it should be something serious such as cancer, I am hoping my Dr delivers the news over the phone in a factual method so I can process the info rather than having to receive the initial news face to face which will result in me blubbering any not gaining anything useful from the visit.

This is to me an inherent difference between folks our age and those older than us. I'd far rather get bad news by phone or in an email than face-to-face. I could then have the opportunity to marshal my defenses and come up with the questions I need to have answered. The whole "call you in to tell you the bad news" seems archaic to me and I have no idea if it is even done anymore, unless you are already in the hospital and the doc comes by to tell you.

Spirit, your story is a moving one; bless you and your family on this Thanksgiving Day.

 

[Meadbh]

About 30 years ago we had a infant son premature never left the hospital and after 4 months it was clear to the doctor that he was not going to make it. The doctor told us that he had a 0% chance of survival, and then went on to answer our questions in a very compassionate manner. He had been giving us updates almost every week for several months, however, that was the final one. My son passed 2 weeks later.

I get to do that a lot. Or at least I used to, in my previous j*b. I find I really have to tailor the discussion based on my relationship with the family, what they have been told already, and what they remember and acknowledge about what they have been told. It's often a process that takes some time, and sometimes other family members can be very helpful. Or not.

 

[bbbamI]

How would you deliver the bad news to your best friend, Michelle?

What would you need from your doctor when she/he tells you the bad news?

I had some tests done this morning and am waiting for results.

I hope everything is ok DM....

 

[obgyn65]

Thank you for sharing, spirit. Like you I am grateful to be part of this ER community. I joined this website a year ago, and I have enjoyed reading and learning so much from all the contributors. Thank you, everyone.

Today is Canadian Thanksgiving and I am grateful for all the wise and caring people who selflessly give of themselves here on this forum.

 

[TromboneAl]

When Lena was having tests regarding headaches, we weren't getting the full story, but the docs could be forgiven because they didn't know yet.

To save some time they sent me to pick up the MRIs. As soon as I got them I pulled them out and looked at them in the car. The golf-ball sized tumor was plain as day.

Things turned out OK.

 

[ls99]

When DW was finally diagnosed with lung cancer, the progression of tests pretty much hinted at what the diagnosis would be. After fine needle biopsy it was confirmed as cancer, and the doc was straightforward. This is Cancer, not-small cell, it looks like stage one or two, possibly three but not likely, can't know until after surgery. If it was small cell it would have been a totally different decision process. We were prepared for either result. Docs know what that means, others can do their homework.

Options were described as removing the cancer, removing the lobe of the lung with the cancer still encapsulated, or do nothing.

DW had no intention of being subjected to radiation before or after. The Surgeon was informed of this decision BEFORE the fine needle biopsy. She and I have seen too many cooked people in extended misery.

She opted for lobectomy, and, as was predicted by the surgeon it was the best option and post surgery the lab was able to determine the correct stage: 1A.

We appreceiated the surgeon's brief and to the point explanation, and thereafter, he was open to and fully responded to any and all questions by DW and I.

Post surgery briefing by him was again brief and to the point. He did fully respond to all of my arcane and probing questions without fudging. In fact he said, I had some of the most relevant and probing questions he heard pre and post surgery from lay folks.

Moral of the story, do your homework, do research, try and understand the problem, the consequences of various treatment methods and their effects on the one with illness and how they effect the caretaker. And ask for plain English explanation if doc or nurse use trade language.

Always keep in mind the question: whose life is it, anyway? It is up to you to answer that question. Be prepared to live with consequences of the nature your answer, for a long time. Because you will. And can't escape it or pass the buck.

Again as in all things in life, do your homework. Or in techie language: RTFM


RTFM= read the f*cking manual.

 

[FIREd]

I personally would want the doctor to go straight to the point using plain English. A bit of empathy would not hurt either.

Here are a few examples of bad delivery IMO:

My wife's doctor is terrible at delivering news in general. A few months ago, DW was feeling really tired and had tests done. Her doctor called on Friday night and said "I have just received your test results back and we need to talk, come by my office on Monday". My wife prodded her for more details, but she refused to say anything on the phone. So we spent the week-end freaking out and envisioning worse case scenarios. And then on Monday, we found out that it really wasn't as dire as we had expected.

A few years ago I had my cholesterol checked. The nurse came back with the results and told me that it was "really, really bad". Her alarmist tone started to concern me but then the doctor walked in, looked at the results and said "meh, you're borderline. With your family history, it's nothing".

Later on, the doctor decided I should get an EKG. While reviewing the results with the nurse, they kept saying things like "do you see that?" "yeah, it's weird". They were talking like I wasn't sitting 4 feet away and staring at them. After a while, I asked if there was something I should know about. "Oh no, you're fine" said the doctor.

 

[michelle]

Thank you to each and everyone that has responded. The information is very valuable to me, and has given me many ideas on how I can improve on this difficult conversation.

Some of you have highlighted some of the obviously poor techniques that some MD's use to deliver bad news. Unfortunately that happens far too often and underscores the importance of trying to do it properly. Half of my mentors used the "pass the buck" technique...ie "We couldn't quite get all the cancer, but now we'll send you over to the oncologist to see what they can do" and the Oncologist is stuck delivering bad news to a patient hopeful for a cure. I vowed during residency that I would never do that. And I always turn my pager/cellphone off. I can only imagine how difficult it is to receive such news from a visibly distracted doctor.

 

[Meadbh]

There are a number of books on this subject. My personal favorite is How to Break Bad News by Robert Buckman He gives one of the most entertaining lectures on this topic or any topic

I have bad news. Dr. Buckman died this past weekend on a transatlantic flight.

Renowned oncologist Dr. Robert Buckman dies on flight to Toronto - Winnipeg Free Press

 

[GregLee]

I have bad news. Dr. Buckman died this past weekend on a transatlantic flight.

Did you need to be quite so abrupt?