tag:blogger.com,1999:blog-32053362.post8920037422954529364..comments2024-03-26T00:25:34.026-04:00Comments on Not Running a Hospital: I hate it when I have to give this kind of newsPaul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger52125tag:blogger.com,1999:blog-32053362.post-70599600083293445022010-09-09T14:12:13.040-04:002010-09-09T14:12:13.040-04:00Might I suggest that any doctor or nurse that must...Might I suggest that any doctor or nurse that must give bad news, consider doing it the following way.<br /><br /> 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. <br /><br />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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-85053642950730301962010-09-07T08:39:53.279-04:002010-09-07T08:39:53.279-04:00I posted earlier that patients don't HEAR much...I posted earlier that patients don't HEAR much of what their doctors say, then here comes this study today:<br /><br />http://www.boston.com/news/health/articles/2010/09/07/study_finds_doctor_patient_disconnect/?p1=Well_MostPop_Emailed3Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-74818186233982753502010-09-04T05:19:41.821-04:002010-09-04T05:19:41.821-04:00Thoughts- Some healthcare professionals are better...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- <br />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. <br /> 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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-31463050057072744962010-09-03T13:44:20.391-04:002010-09-03T13:44:20.391-04:00As a physician who considers herself to be both co...As a physician who considers herself to be both compassionate and well-spoken, I take exception to Olga's demeaning generalization:<br /><br />"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."<br /><br />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.) <br /><br />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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-28603722201520434032010-09-03T01:45:36.919-04:002010-09-03T01:45:36.919-04:00Giving news like in this situation is difficult. Y...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.Shelleynoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-36245804908246847472010-09-02T23:30:04.210-04:002010-09-02T23:30:04.210-04:00The baby boomer generation started and continues t...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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-49185058420092504582010-09-02T15:21:50.301-04:002010-09-02T15:21:50.301-04:00Sometimes even good news can be delivered badly. &...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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-15766728782732674422010-09-01T06:14:04.042-04:002010-09-01T06:14:04.042-04:00To be clear, no one was angry with this young doct...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!)The husbandnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-30889410111999035172010-09-01T05:47:39.679-04:002010-09-01T05:47:39.679-04:00Never easy but it is a sad reflection of US health...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'.sasanofhttps://www.blogger.com/profile/17025850427800846235noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-13875360785786083432010-09-01T01:03:52.683-04:002010-09-01T01:03:52.683-04:00Tom and Peter E. have excellent comments.
I agree...Tom and Peter E. have excellent comments.<br /><br />I agree that grief is accompanied by anger, which will often be directed as us as caregivers. <br /><br />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. <br /><br />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. <br /><br />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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-13398333594917363992010-08-31T22:10:52.538-04:002010-08-31T22:10:52.538-04:00As a primary care physician for over 20 years, I h...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:<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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).<br /><br />No matter what you say, though, it is not easy, in my experience.Larrynoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-10714560519795438512010-08-31T22:05:32.252-04:002010-08-31T22:05:32.252-04:00I am a Hospitalist. I frequently have to deliver b...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.<br /><br />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.Kevinnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-25227310608388605292010-08-31T06:18:56.360-04:002010-08-31T06:18:56.360-04:00This is a tricky situation, as it is easy for a ph...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.<br /><br />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.<br /><br />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.<br /><br />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.An older ED docnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-45103843643606520532010-08-31T06:05:23.048-04:002010-08-31T06:05:23.048-04:00Truth with sincere empathy.Truth with sincere empathy.BMnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-7995280541170559692010-08-31T04:57:53.365-04:002010-08-31T04:57:53.365-04:00From experience I can tell you that for me, a dire...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.<br /><br />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.Bettynoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-13741893922920052092010-08-31T02:20:48.063-04:002010-08-31T02:20:48.063-04:00I agree that with some of the comments that the po...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. <br /><br />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. <br /><br />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.Eric Widerahttp://www.geripal.orgnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-64184010974773076872010-08-31T00:57:34.454-04:002010-08-31T00:57:34.454-04:00How do you know that the physician said what the p...How do you know that the physician said what the patient said that he said?76 Degrees in San Diegohttps://www.blogger.com/profile/14358630186174729315noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-43650368736766877432010-08-30T23:22:38.235-04:002010-08-30T23:22:38.235-04:00What is called "Doctor harassment" is on...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.<br /><br />The case presented here is not that all bad comparing with the cases in Japan.<br /><br />I am quite interested in the american doctor training system regarding with patient communication. There are few communication trainings provided in Japan.acesuzukihttps://www.blogger.com/profile/03102106105697985933noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-66361517034067941202010-08-30T22:13:16.391-04:002010-08-30T22:13:16.391-04:00This particular turn of phrase, while meant to be ...This particular turn of phrase, while meant to be empathic, is wrong for the exact reason that Paul says. Furthermore, <i>Anonymous</i> 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.<br /><br />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, <i>"nobody cares how much you know until they know how much you care."</i><br /><br />Something that I think is too often neglected is informing the patient when doing the test/scan that one of the things that <i>might</i> 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.<br /><br />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.Peter Everettnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-35112879938424085452010-08-30T18:21:54.566-04:002010-08-30T18:21:54.566-04:00Dear Paul--Thank you for bringing this very diffic...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.Diananoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-4658768415028511122010-08-30T17:41:56.981-04:002010-08-30T17:41:56.981-04:00My mother always said, "don't listen to w...My mother always said, "don't listen to what I say, listen to what I mean." <br /><br />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.<br /><br />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. <br /><br />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.<br /><br />I would worry more about this interaction if it did NOT include <br />some acknowledgment of the horror of the information he was about to share.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-19697967102719453582010-08-30T17:20:23.108-04:002010-08-30T17:20:23.108-04:00I left the impression, unintentionally, that I had...I left the impression, unintentionally, that I had this experience, when I did not, but knew about it.<br /><br />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.Patientnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-61352223954840857472010-08-30T17:14:49.332-04:002010-08-30T17:14:49.332-04:00I'm going back to the first post from Wong ML:...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."<br /><br />Could he possibly be the fabulous infectious disease guy at BIDMC?<br /><br />I love his approach.mdspencernoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-67454649901372984912010-08-30T17:13:48.579-04:002010-08-30T17:13:48.579-04:00I couldn't agree more. The bearer of the bad n...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.<br /><br />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.<br /><br />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?Howardnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-4764701740874523682010-08-30T16:56:58.901-04:002010-08-30T16:56:58.901-04:00I've read only the post not other comments. M...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.Brendahttp://www.estherhasalivingwill.comnoreply@blogger.com