Sunday, August 29, 2010

I hate it when I have to give this kind of news

Sometimes an expression that would be appropriate and kind in normal circumstances can add pain or anxiety in a clinical setting.

A friend recently went to the Emergency Room because of some bad symptoms. After a few tests, the attending returned to give the diagnosis. He started out by saying, "I hate it when I have to give this kind of news" and then proceeded to summarize the test results and finally to tell my friend that she likely had a very serious, probably terminal form of cancer.

I think what happened here was that the doctor thought that his introductory clause displayed empathy. But what this patient and her spouse heard was that the doctor was more concerned about what he was feeling than what the patient was feeling. Especially after they found out that, no matter how badly he felt, it was the patient who was likely to suffer and die.

Further, in the extended minutes of explanation before he actually delivered the diagnosis, his introductory comment caused a heightened level of stress. He felt the explanation was important to provide a context for the conclusion, but it mainly served to create suspense.

They would have preferred a more direct, "I am sorry to have to give you some bad news. We believe you have ** cancer. Let me explain why we think so." In their minds, the slight change in wording would still have presented empathy but would have made clear that the doctor's concern was about them and not about how badly he felt. The direct delivery of the diagnosis at the start of the explanation would have relieved suspense.

Some reading this might feel that my friend and her spouse were overly sensitive and were misinterpreting common courtesy. I can only respond that these folks' reaction was immediate and negative. I conclude from this that common courtesy does not always feel like such in a difficult clinical setting.

I claim no expertise in how bad news should best be delivered by doctors. But I have told this story to other people with serious diseases, and they have resonated with the feelings of this couple, often remembering their own moments of diagnoses in a similar fashion.

I would love to get reactions and wisdom from both clinicians and patients on this matter. Please comment.


WongML said...

How about:

"The results of the tests are back, and they're not as we hoped."

wrinkledman said...

I'm with the patients on this one. Any person who is already fearing the worst wants bad news outright, not through the lens of a doctor's feelings. Although the doctor's intentions might have been to be sensitive to the patient, his or her delivery was most certainly not the most sensitive way to inform, particularly under the circumstances. If he had been delivering good news, a little suspense and his own feelings would not have hurt a bit. Hopefully the doctor has recognized the insensitivity, owned it, apologized and moved on. We all get better with practice, particularly if we can recognize and acknowledge our mistakes. My heart goes out to the patients. They sound like thoughtful and forgiving people and it will serve them well in their fight with this disease.

PJ Geraghty said...

I like WongML's answer. In fact, I will use that elsewhere in my training/coaching of docs who have to deliver bad news.

When I had my own near-death experience, I was told by the medicine resident that my condition (a saddle pulmonary embolus) " usually diagnosed on autopsy!" Though pleased that I would survive, I did some very terse directed teaching about delivering such news in the future.

I would encourage the patient in this circumstance to address this with the ED physician in a calmer setting (certainly I would not have expected her to do so after hearing such news). Likely the doc didn't think about what he was saying, and was using words to fill space--a dangerous habit for all of us.

Pat said...

A recent article in the Journal of Clinical Oncology explored "how docs give us the bad news." Some are empathetic, give the news in private settings, and patients, despite the bad news, feel cared for (or about). Others had the news delivered in impersonal settings, such as the ER or in one case, the patient even read it on a lab test result. Pat Salber, MD, The Doctor Weighs In

catsandmusic said...

The Emergency Room is a semi-public sort of environment. I hope this patient was at least taken to a room instead of being told in a curtained cubicle where the conversation could have been audible to other people.

Canuckle said...

A difficult and far too common experience for the patient and their family.

The science behind risk communication was based on studies of physicians delivering terminal diagnoses. These support following the order of Compassion, Courage, Optimism when delivering bad news or responding to a crisis (where Courage is when you disclose the specifics of the bad news).

This process is proven to be the most effective -- and appreciated -- by the audience, including patients.

However, the science also shows that How the message is delivered, both verbally and non-verbally, greatly affect credibility and rapport.

Hopefully, the patient gave their physician the feedback on how they felt after he delivered the news and he can make use of the tools and courses that are out there to improve his practice.

Michael Pahre said...

You're right on in your assessment.

The comment, "I hate it when I have to give this kind of news," is something that a doctor ought only to say, privately, to a colleague or spouse. Not to the patient.

Anonymous said...

When I have to give the big "C" news. I usually preface it with, "I don't have any good news for you. Your biopsy shows...."

I too hate giving that type of news, but my discomfort is slight compared to what my patients experience.

Anonymous said...

a) This story seems apocryphal. It is difficult for me to imagine a terminal diagnosis that could be given in an emergency room. Work-ups for most serious diagnoses take days, weeks; biopsy results take at least three days to come back.

And if a biopsy was performed in the ER -- and the final results were of course not yet available -- he did a diservice by "assuming" the answer was what he was saying. Our patient lists are FULL of people who had biopsies for what clearly "appeared" to be malignant and then turned out to be benign.

And I have to ask -- what kind of situation demands that a totally unknown ER doc give this kind of news? Why wasn't the patient -- as is much more common -- sent back to his PCP or an oncologist.

2) I think there is no one way to give bad news. Some people need a warning phrase (as he gave). Some people need to hear how the doctor is reacting to the news -- there are many reports of patients who remember their doctor's dismay and anguish as a good thing.

2) Strange doctors (eg ER docs) can have no way of knowing what way a new patient might prefer to learn such news. All doctors can't read every patient perfectly.

3) It is incredibly common to be angry at the messenger rather than the news, or even at god.

4) There is no good way to get this news. There are good and bad ways to give the news (I don't particularly dislike this one) but there is no good way to get it. Virtually no one thinks that moment went well, no matter what the doctor did or said.

I personally think you should cut this ER doc a break. He was clearly at least trying to do to the right thing....

Anonymous said...

As a pathologist, my experience lies in delivering such news to the patients' physicians, which one might be surprised to learn is often received with similar (although of course not the same) anguish.

But, I have not forgotten a years-old case in which a patient and husband came in our office just at the secretaries' quitting time and demanded (yes, demanded) a pathology report which they already knew, by phone from their physician, indicated high grade breast cancer. I had not yet dictated the final report for typing, and they literally stood in my office doorway as I did so.
Perhaps distracted, I inadvertantly dictated "right" instead of "left" breast. Although I caught the error right away and it was unsupported by data elsewhere in the report,they seized upon it to declare that this must be someone else's specimen and the entire diagnosis was wrong - becoming extremely angry in the process.

One never knows how patients will receive such news, and we can only be as compassionate as possible.

nonlocal MD

Patient said...

Apocryphal, Anonymous? Nope. Every word true. The bizarre thing is the doctor, not the diagnosis. That she or he said it, not that it exists.

Take it out of the ER and still, I know too many patients who have received their C news this way. It is a cold, self-centered method when a patient most needs compassion.

Anonymous said...

From Facebook:

Suzie: I agree with you, the choice of words, tone and empathy can make bad news worse because the patient may feel abandoned at the moment when inclusiveness and tenderness could cushion the shock.

Martha: When we received the diagnosis of cancer, the doctor said, "I know what you have, I know how to treat it, and you start treatment next Tuesday." He was very positive that things would work out, even though the diagnosis was not good. Fortunately, it has.

Amanda: I agree with you. From working in a hospital setting for so long, I would watch the doctors with their patients. Sometimes I think doctors are so brilliant and know so much about medicine that they forget that a patient is a person, not just a room number. However I can also see the other side of that. Anybody can become attached to a patient and become sad having to give such news. But thank goodness for doctors because they are there to help all sick people.

Thomas: I vividly remember when the doctor informed me I had cancer. He was typing on his lap top with his back turned to me, and slipped in between "X test shows this and Y test shows that" was a quick "probably cancer". I actually had to ask him to stop typing, turn around, and engage in a conversation between just the two of us -- no phone, no computer, no distractions. Surely there has to be a better way than that to communicate with your patients.

Brenda: I don't know if it comes from training in which we are taught to present our evidence before our conclusions, but I think giving a hint that bad news is coming, and then holding the bad news until the end, happens more than we would like. The suggested wording of "I am sorry, but we think you might have X" is much more fair to the patient. We truly are sorry, but it is not about us, and we need to always keep that in mind. The best physicians I know can navigate these conversations with compassion and care. I think practicing these conversations before talking with a patient might be helpful to those who are uncomfortable having them.

Tricia: Your friend is very wise and has a great point in regards to therapeutic communication which is so important, but often forgotten, especially in the ER setting. It is not incredibly often that this kind of news is discovered and delivered in the ER, and most doctors/residents do not have the time to prepare a proper delivery.

Perhaps it would be helpful to always have a nurse in the room to listen to all of the information and "translate" it back to the patient after the initial shock has lessened. I am very sorry for your friend and for the way she received the news. This can be a big learning experience in the ER for future situations.

Vicki: Martha should shout her doctors name from the rooftops.

Anonymous said...

More from Facebook:

Karla: A moment that lives with me forever was when my son was diagnosed with Nephrotic Syndrome. It started with what I thought was an allergic reaction to some calamari he ate at a family function. When my pedi asked for a chest xray (for an allergy?) I knew something was up. He lead in with asking questions about family history and then told me what he suspected and he sent us to Children's. At Children's it was such a hurry up and wait, it was frustrating. I watched my toddler and his brother playing with Hot Wheels and Thomas the Tank Engine toys while we waited and waited and waited. When the doctor finally came in (the delay was finding the on-call nephrologist), I was handed a blue folder, given a technical lecture about the kidneys, a script for prednisone and sent on our way with a follow up appointment.

I was stunned and numb. A technical lecture and a blue folder of info. As I said to at least one person along the way, "He may be the millionth kid you diagnose, but it's the first time we're getting a diagnosis. Please be respectful of that." That is the key as well as the hardest thing to remember.See

Jessica: I think that Medical students and Physicians should have sensitivity training and be video taped and tested on a periodic basis to ensure they have a good bedside manner.

Amanda: ‎@Jessica -- That is SOOOO true! And not just the doctors, but all staff!!!

Vicky Lindo de Kemish said...

In my facebook comment I had thought of saying something akin to what Anonymous said regarding the giving of such diagnosis from the E.R. But I kept my laymen's thought's to myself. Now that he/she has spoken, I want to second the notion that, worse than getting devastating news in the E.R., might be getting erroneous devastating news.
What occurred to me was that the E.R. doctor might have said. "We've made these tests and had these results. You will need more tests. We'll pass all this on to your doctor and he/she will follow up with you"
At that point the patient (depending on their particular character) will ask for more info or not. This way the patient really does get the news in a way that is potentially gentler and more in their control.

Mark Montgomery said...

I have been enjoying your blog-- congratulations for rare bravery in an industry that needs a great deal of cultural reform.

My brother was diagnosed with ALS in a similar manner, but after test results.

The short answer is that a death sentence shouldn't be delivered by a clinician--while some are no doubt better than others, I have dealt with thousands of scientists in my career, and carry the banner in my own work-- they are too close to the science and too far removed from the patient's life and emotional state to have true empathy.

In the old days, a GP who had known the family for many years and learned some humility and to check the ego at the door would have been more appropriate in many cases, but as we know those days are largely gone.

As to whom? Think Hospice as a culture and training-- clinical details will come later. In most cases patients and their families will have an enormous learning curve before they understand the clinical issues sufficiently (if ever in many cases no doubt)to make good decisions, anyway.

The husband said...

Paul, I think my wife and I are the couple profiled in your post. I am also sorry to see that "Patient" had a similar experience. And sorry to read that "Anonymous" doesn't believe this happened.

In our case, the first thing the albeit youngish doctor said was "This is why I hate being a doctor." He had his hand on his chin, his head down. Then, as I recall, he said something like "I never know how to do this." In other words, he told us without telling us. He went on to be specific: a large tumor on the pancreas, a lesion on the liver, and a possible spot on the lung.

Frankly, Anonymous, none of it has ever been biopsied. It is four months later and I'm writing this from the lobby of the same hospital where, at this moment, my wife is undergoing radiation (and is in the fourth round of chemo).

My wife, a writer herself, has been recording all that's happened including the truly sensitive moment when a very close friend, who
heads one of the medical departments in the hospital, visited her the next morning to explain the prognosis. "Some of my patients have lived as long as a year," he said. No b.s., no pretty-ing it up, for which she was very grateful.

We laugh when we tell the ER doc story. We have to laugh because if we don't ...

Patient, my heart goes out to you. All of this, in a word from that ER doc's generation, sucks.

Anonymous said...

Empathy is crucial when delivering diagnoses. Catch phrases without real compassion behind those expressions are always transparent to the patient; so it has to be heartfelt.

Trisha Torrey said...

This is a great question, Paul - one I have experience on the "don't do this" end.

My cancer diagnosis came after surgical removal of a lump from my torso. Two weeks later, the surgeon called me at home at 7 PM - yes, by phone - to tell me I had subcutaneous panniculitis-like T-cell lymphoma, that he didn't know anything about it except that it was terminal, quickly - and that his office would call me in the morning to refer me to an oncologist. It was horrifying, just horrifying.

I think most patients want you to be straight with them. Sugar-coating isn't required, but a certain amount of empathy is gladly accepted. Hope, when possible, can mean a lot in how the patient walks out the door, and the decisions he/she will make from there. Hope that is unfounded isn't really useful at all.

That's 2 cents from someone who has been there and experienced only the bad.

Trisha Torrey
Every Patient's Advocate

Anonymous said...

As a therapist, hospital administrator and person who has “received bad news”, I would have to say that there is likely no good way to tell someone something that they really don’t want to hear. It sounds to me that the attending was as sensitive as he knows how to be. Physicians are humans, each with their own unique strengths and weaknesses. No one knows how to give bad new without having the receiver respond with shock, terror, anger etc. If there was a way to do it – I would love to market that skill.

Anonymous said...

To be clear, that last comment was not mine, but one that was sent to me by email for posting . . .

Anonymous said...

I second anon 11:39. Something about this post has been vaguely bothering me, and s/he said it well.
I think we can learn from the comments which offered a better way to do it, and I hope, Paul, that this information is conveyed to those responsible for training tomorrow's physicians so they may do better. I always like to focus on a systemic method to improve a situation rather than dwell on the negative.


Anonymous said...

Empathy, balanced with honesty is crucial.

A year ago, I unfortunately was with a relative who was diagnosed with terminal cancer. The doctor delivered the news with utmost compassion -- the only thing I wish she had done differently was give a realistic timeline when my aunt asked. The doctor said 1 year and "put your affairs in order". We all knew it would be much sooner based on the pathology. My aunt died almost 1 month after being diagnosed -- she knew it wasn't going to be long and quickly "put her affairs in order" and really enjoyed her remaining days, without sadness, denial or regrets -- she understood the reality of her situation. It would have been helpful for her husband (elderly and in denial) to have heard "3 - 6 months" -- vs. "a year" to better help manage his expectations (most importantly deal with the rapid increase to my aunt's pain meds -- it was a constant battle with him, trying to explain the urgency, when he was clearly focused on "1 year").

I often wonder how I would have given that grim diagnosis if I was the doctor; would I have the courage to tell someone they have less than 3 months to live -- and not be affected by the message on the commute home? All in a day's work I guess.

Unknown said...

I think you hit the mark when you wrote "Especially after they found out that, no matter how badly he felt, it was the patient who was likely to suffer and die".
It is true how bad one may feel, you can never feel as bad as the person who is getting the news.

Your point is well taken. My wife is an oncologist and she usually follows the protocol of not showing her own emotions how she feel. On the other hand some of us feel the "guilt" of being the messenger of bad news.

This scenario is very similar to when we ask a family member to decide the code status for their loved ones. Occasionally family members feel "guilty" when they have to decide whether they should change the code status to comfort measures only ("pulling the plug") versus their own selfish reasons to to keep the person alive by life sustaining measure.

I try to advise them to think what their loved ones wishes were. i often hear that "I did this for my mother, I can't do this for my father too".

I will keep this in mind.... the lesson is, no one likes to be in suspense.

Irfan Ali

Anonymous said...

Presenting and explaining a diagnosis/prognosis to patients is part of patient care -- hopefully patient-centered care. Full stop.

Anonymous said...

When the doctor told me that I had cancer, I started screaming at him. I felt offended that he would say that to me. Now that I'm 3 years out from the diagnosis and well, I feel horrible that I acted as bad as I did. I yelled at my mom too because she wasn't "defending" me from the doctor. He did say that he hates giving news like that. It didn't bother me because I would hate it too. I felt compassion from him when he said it.

Tom said...

I don't claim expertise either. I do, unfortunately, have alot of experience. I'm a hospitalist. My thoughts are similar to yours, and include:

* Make sure that, if the patient wishes, family is present
* Sit down
* Block off plenty of time so questions can be answered thoroughly
* As you said, be direct and honest, including honest about prognosis and what can be expected in terms of benefits and side effects of potential treatment, like palliative chemo or radiation
* If other physicians are involved let them know you are having "the talk" so they can be prepared as well. Make sure you know their opinions so the message is clear and consistent
* Don't shirk the responsibility. You would be surprised how many end stage cancer patients currently under treatment, getting chemo or RT from an oncologist, do not know about their prognosis or that their treatment is palliative in nature. They show up in the hospital, often with complications of treatment, or just with symptoms of progressive disease. At times the patient is in denial, but usually is is simply that no one has been direct with them. And I don't think it is usually for a financial motive (although I am sure at times it is). I think the problem is just reluctance on the part of many oncologists or PCPs to do what they consider "dashing someone's hopes"
* PCPs (including hospitalists) need to take charge. Every time a specialist gets involved the tendency is to offer a treatment. It is up to the PCP and the patient (and their family) to decide if the offered treatment is consistent with the patient's goals. For terminal patients, offered treatment often is not
* Be prepared to honestly offer hope. This can include an offer of hospice services. Almost all terminal patients, with the proper physical help and medical intervention, can have their symptoms controlled and stay at home. Many can remain physically active
* Use the hospital chaplains

Anonymous said...

How I learned I had Ovarian Cancer:

I was still relatively young and hoped to have children. My surgeon was under strict instructions to remove only the mass on the ovary and the one ovary itself, if it could not be salvaged (suspected recurrence of endometriosis, no one was worried it was anything more). Absolutely NO HYSTERECTOMY!

upon awakening in recovery, the recovery nurse, seeking to orient me to time and place, no doubt, informed me I was in recovery and had just had a total hysterectomy. Then she walked away. I sobbed and sobbed. She didn't know, I assume - but really - the surgeon should have told her the circumstances. It was horrible. I had to wait a couple of hours until I was transferred to my hospital room before the doctor came to tell me the news. Silly me, I was so cowed by the whole experience I never told him the awfulness of learning the news in such a cold, uncaring way.

Brenda said...

I've read only the post not other comments. My experience is that patients are not told outright that the pronosis is poor. Euphemisms, vague responses, and language barriers all make a stressful situation more so. Doctors are not seers and can't give definitive time frames, but they should at least give a plain language diagnosis that leaves the patient with no doubts about their condition. And your friend is absolutely correct, patients don't care what the doctor feels.

Howard said...

I couldn't agree more. The bearer of the bad news is being insensitive to the patient and should think a bit more about what the patient's needs are and what the patient wants to hear.

A similar phenomenon happens in the business world and perhaps a clinical setting and the business world should share management skills and techniques and learn from one another. In my career I've been on both sides of the firing / lay-off table. It hurts employees to hear the boss say things similar to what was said in the above clinical example. In fact, doing so generally causes a more uncomfortable and sometimes even hostile "conversation". Good management training teaches that these sorts of conversations are about the employee (or the patient & their family, in the clinical setting) and how to approach the conversation in a sensitive, productive way. It is common sense to most people, but then again unfortunately most people don't think about it in this light until it is explicitly brought up in the first place... or until it is too late.

I applaud the patient and their family for bringing this issue to the hospital's attention. I leave you with this thought: Perhaps the psychology of patient interaction should become a required part of employee training rather than a lesson that each bearer of bad news must learn on their own?

mdspencer said...

I'm going back to the first post from Wong ML: "The results of the tests are back, and they're not as we hoped."

Could he possibly be the fabulous infectious disease guy at BIDMC?

I love his approach.

Patient said...

I left the impression, unintentionally, that I had this experience, when I did not, but knew about it.

My own MDs are extremely good at giving bad news. But I've heard from too many people who have this experience as posted. Shame on any doctor who thinks his/her feelings are the most important.

Anonymous said...

My mother always said, "don't listen to what I say, listen to what I mean."

This "youngish" physician's words were poorly-chosen, obviously, but he clearly MEANT to convey how dreadfully sorry he was to have to be the bearer of such terrible, life-altering news. I sincerely doubt he was looking for any "sympathy" for his own discomfort or meant to downplay the patient's discomfort in any way.

His words are essentially "I'm sorry to have to tell you this. . ." or "I hate to have to tell you this. . ." which, in my mind, is a way of expressing sorrow for the patient's diagnosis and an expression of empathy.

It is not hard to imagine his going home that night and telling his significant other "I had a terrible day, I had to tell a patient some very bad news." This by NO MEANS means that he is feeling worse for himself than for the patient.

I would worry more about this interaction if it did NOT include
some acknowledgment of the horror of the information he was about to share.

Diana said...

Dear Paul--Thank you for bringing this very difficult issue into public discussion! I feel for the patient and family--for the pain they have had to encounter, and I also feel for the clinician, who seems--genuinely--to not know how to have these difficult conversations with patients in a way that lets him be human and genuine, and express the compassion that likely brought him into the field. These are not easy skills to learn! It speaks to the need for medical education, CME, and in-house training to support clinicians and help them to be at their best when they are addressing patients in life-altering ways.

Peter Everett said...

This particular turn of phrase, while meant to be empathic, is wrong for the exact reason that Paul says. Furthermore, Anonymous makes the excellent point than Emergency Dept. physicians generally don't have the time or information needed to deliver this kind of news, as some workup is generally required. For example, I've had a patient who learned of his cancer diagnosis from a doctor in the ED who basically said, "you're terminal, get your affairs in order," for a lymphoma that was likely to be either curable or controllable for many years with appropriate treatment. I've had another patient with a large, non-malignant, obstructing, inflammatory mass in the pancreas secondary to alcoholic pancreatitis told he has locally advanced pancreatic cancer and will likely be dead in 6-12 months.

There are well-established right and wrong ways to convey this kind of news, however, no one way is right for all doctors or all patients. There is a whole literature on "giving bad news" that doesn't need to be recapitulated here. It was a part of my medical school training, and again in residency. However, no amount of training can substitute for a serious dose of humility, and actually caring. As the adage goes, "nobody cares how much you know until they know how much you care."

Something that I think is too often neglected is informing the patient when doing the test/scan that one of the things that might result is a cancer diagnosis. When cancer is on the differential, words like, "Jaundice can be caused by many things, most of them not terribly serious, but sometimes it is caused when a cancer obstructs the liver. This test will help determine...," can lay the ground work for the conversations to follow.

Absent a pathologists report, physicians in the ED or anywhere else should think long and hard before saying anything more definitive than, "this looks like some sort of cancer, one that has spread, but a tissue sample is needed to be sure." I would also add some sort of acknowledgment that such news news is hard to hear, and usually ask the patient how he or she feels upon receiving it, and what kinds of questions it raises in his or her mind.

acesuzuki said...

What is called "Doctor harassment" is one of hidden issues in cancer treatment in Japan. It happens especially when doctors tell the patients that they found cancer or they had no options but best supportive care.

The case presented here is not that all bad comparing with the cases in Japan.

I am quite interested in the american doctor training system regarding with patient communication. There are few communication trainings provided in Japan.

76 Degrees in San Diego said...

How do you know that the physician said what the patient said that he said?

Eric Widera said...

I agree that with some of the comments that the poorly-chosen words seem to be used to communicate the physician's sadness in delivering this horrible news.

Empathy for the patients condition though should make one think that the sadness we feel is not even in the same ballpark as what the patient and their loved one is about to go through. A line like, "I hate when I have to deliver this type of news" may be best reserved when discussing our reactions with our colleagues, as it may seem to patients that this is just another task in a busy day that you hate to do.

A short brief shot over the bow of "I have difficult/bad news to tell you..." can still convey empathy for the patients situation without trivializing their anguish.

Betty said...

From experience I can tell you that for me, a direct honest approach works best. Don’t tell me that 97% of biopsies are benign because when I fell into that 3% I felt like a damn loser.

When my father was diagnosed with brain cancer, I asked the doctor to detail what I could expect. Thankfully he did and I was able to take my Dad home and care for him during the three weeks he had left. Precious, precious time not wasted in the hospital.

BM said...

Truth with sincere empathy.

An older ED doc said...

This is a tricky situation, as it is easy for a physician to misspeak when struggling to break horrible news (something we fortunately do very rarely in the ED). Although this was an error on the physician's part, part of why this has come to our attention is the need to lash out when one has horror thrust into your life, even if the person who breaks the news isn't responsible. What is really a social fumble can become a focal point for families. As doctors, we should certainly avoid adding insult to injury.

There is no standard way to do this nor has it been studied, although there are plenty of opinions. My experience suggests that it has to be adapted to the specific patient (e.g., age and baseline medical condition, type of rapport between the physician and the patient, presence or absence of family or other support, availability of a PCP to participate or guide, how definitive the diagnosis is, how lethal the underlying condition and what the life expectancy is). I once had an 18 year old girl, a foreign visitor, in whom we made the diagnosis of metastatic ovarian cancer. Isolated and far from her family and home, it would not have been safe to do more than communicate to her that she had a very serious illness, get her permission to talk to her parents, and coordinate the next steps in her care to give her the best chance. But the ED was not the time and place to tell her she had a lethal diagnosis that was quite likely to kill her in a relatively short time frame. Each case may need a tailored solution.

This doctor clearly fumbled while searching for a way to break the news. It's easy to understand how this could happen with a young physician, particularly since dealing with this sort of information is relatively rare for an emergency physician. This is more an opportunity for improvement than finding fault with the physician.

It's also a good discussion for us to have in the ED staff meeting to raise awareness of how the best intentions can easily go astray. But the real solution for each Emergency Department is to define the right way to handle this and to train for it. I think that connecting with the oncologists and psychiatrists to put together the best approach is the way to go. It might be that we should defer giving the full bad news until we have someone available that has a history with the patient. Or we may want a standard script along the lines of some of the responses here on this blog. We might even consider having psychiatry join us, as they are present in the ED, and this is a terrible psychological blow.

Kevin said...

I am a Hospitalist. I frequently have to deliver bad news, and I agree that the ED physician's remarks are dreadful. I also hate it when I have to deliver bad news, but would never state it this way.

I always try to steer clear of using "I" as this is about the patient, not about me. I do use the word cancer or probable cancer, and do not like to dance around it by saying tumor, growth, nodule, etc. I will talk about how we came to the diagnosis, but after giving the diagnosis, most patients do not retain much. I always ask if there are other questions, and arrange a time to come back to answer the inevitable questions that will come, and offer to meet with the family and loved ones.

Larry said...

As a primary care physician for over 20 years, I have been in this position several times, and there are a couple of principles I use to deliver bad news that I would like to pass along:

First, there is NO good way to deliver bad news like this. You can’t soften the blow, make seem not so bad, or “protect” the patient from the truth, and trying to do so only makes it worse.

Second, patients and their families are only able to really process so much of this kind of information. Trying to give them all the details is fruitless and only causes confusion. Be to the point, and answer questions, understanding that more information will be needed LATER.

Never give this type of news over the phone, or ask somebody else to do it. You would be surprised at the stories I hear of physicians asking their nurse or assistant to call the patient with the news, or even calling themselves. One caveat needs to be given here. There are circumstances whereby you don’t want to take the time it will take to establish an appointment and have the face to face conversation (e.g. an urgent referral is needed and the patient needs to know why), but ALWAYS deliver the news yourself.

I find that the best way to deliver bad news like this is to tell the patient “I have to tell you what is going on here, even though this is not what you want to hear. You need to know that…” It is important to touch the patient (just a hand on the shoulder, etc.). Beyond that, you have to tailor the message to the individual. Some need to hear the message a couple of times. Some need to see the pictures or lab results. Some will want to know “how long do I have” (I usually avoid giving specifics here—they usually are going to need to be seen by somebody else, too, who will give input into options and statistics).

No matter what you say, though, it is not easy, in my experience.

Anonymous said...

Tom and Peter E. have excellent comments.

I agree that grief is accompanied by anger, which will often be directed as us as caregivers.

Somebody wondered whether an RN should/could have been available to help interpret after the physician withdrew. I am an RN and have made it my practice to round with physicians as much as feasible because almost invariably the physician's message is so poorly communicated.

I see this lack of ability to honestly and humanly communicate as a symptom of our whole health care mess. We're so busy caring for the system--meeting the needs of the payor, regulators, our call partners, etc that we've lost track of the very person to whom we are (or should be) most accountable. I have been sad for most of my career that medical training--especially surgical training--seems to have knocked the humanity right out of so many doctors.

On the positive side, my work with midwifery and hospice has shown me that there are pockets of professionals who DO know, and train, outstanding communication skills.

sasanof said...

Never easy but it is a sad reflection of US healthcare that such a diagnosis is given in an ER. We would all benefit from reading John Updike's "Endpoint" - a poetical assessment of end of life 'care'.

The husband said...

To be clear, no one was angry with this young doctor. We both felt sorry for him as he clearly was struggling and we're the kind of tell-it-to-us-straight types who prefer no euphemisms. We wanted--and continue to prefer--the worst-case view because then if things turn out better we can only be pleased. Please don't think we blamed or lashed out or are in any way displeased with this doc. We didn't and don't and aren't. He did everything else very well, including ordering the proper tests very quickly. He just needs more training in communication, particularly in how much time to spend delivering the news. His first "probable diagnosis" was delivered in under 2 minutes. Google delivered the rest of the story. (And never send a shrink in with a doc to deliver a terminal diagnosis--that's nuts!)

Anonymous said...

Sometimes even good news can be delivered badly. "You were cured by the biopsy" was not very welcome as I awoke from a mastectomy and lymph node dissection.

Anonymous said...

The baby boomer generation started and continues to propagate our culture of hyper sensitivity. Good Lord...bad news is bad news. Get, give it, whatever and get on with things. Instead, we waste time whining about the need for more sensitivity, understanding, settings etc. and blather about a friend of a friend who was really upset at the messenger. Talk about displaced feelings.

Shelley said...

Giving news like in this situation is difficult. You don't want to make things sound worse than they are. It is important that the person or any Medical Professional show concern and empathy towards a patient. It is important to put yourself in the patients situation and to be sensitive to a patient's feelings. I agree that stating something such as: "I am sorry to have to give you this news..." is better to say "I hate it when I have to give this kind of news". I don't think the doctor intended it to come out the way it did because i believe that this is a difficult thing to do.

Anonymous said...

As a physician who considers herself to be both compassionate and well-spoken, I take exception to Olga's demeaning generalization:

"Somebody wondered whether an RN should/could have been available to help interpret after the physician withdrew. I am an RN and have made it my practice to round with physicians as much as feasible because almost invariably the physician's message is so poorly communicated."

It should be remembered by all that "communication" is NOT just the giving of information but also the receiving of information. It is well-known that patients hear only about 20% of what the physician says, even less when the content has highly emotional implications (hence the abundance of written information we constantly provide.)

I respect Olga's abilities as a nurse and as a communicator (despite the fact that she does not respect mine) but her remarks should be interpreted in the context of knowing that since nurses physically spend so much more time with the hospitalized patient each day, they are simply the ones who are more available for answering questions the patient may not have been able to ask and offering explanations that the patient may not have been able to process until they were able to absorb the shock of hearing the initial bad news.

Anonymous said...

Thoughts- Some healthcare professionals are better communicators than others. I hope I have learned humility over the years dealing with death of my patients, deaths in my family and a son who is a Marine facing death daily-
As a 25+year Surgery RN,- if a patient dies in surgery I offer to go with the surgeon to speak with the family- its one of the hardest thing to have to hear (or say) after surgery that is thought of as "fixing" something. Maybe that is why the Marine Corps send two people to inform families of a death. It may not be "about" the person giving the news but it does affect that person deeply.
The very first post (Test results not as hoped) was simple, direct and respectful-it could be used in many poor outcome scenario. That is how I would want to be spoken to.

Anonymous said...

I posted earlier that patients don't HEAR much of what their doctors say, then here comes this study today:

Anonymous said...

Might I suggest that any doctor or nurse that must give bad news, consider doing it the following way.

Look the patient directly in the eye and imagine that person is your most important loved one, then tell the patient what they need to know, in just the way you would want your loved one to hear it.

I expect you will find that the patient while upset/stunned etc will have heard you loud and clear and be able to ask questions or listen to plans of action.