Delivering and Hearing Bad News
We all have a story about the moment we learned of our cancer diagnosis or, even worse, when we learned that the cancer had returned and/or progressed. For me, back in 1993, it was being invited into a small conference room after the breast biopsy to speak with the surgeon. Before I saw her, I saw my husband's back; I vividly remember that he was wearing a black and white striped shirt, and that shirt, that back, told me everything. If all had been well, he would not have been there.
There is increasing attention being paid to educating doctors how to give bad news, and, certainly, how to deliver really bad news. From our patient perspective, we are hearing it. We surely want our doctors to be as gentle, as tactful, as hopeful as possible. We also want them to sit down to have this conversation, and we want them to be human. We don't want them to drop a bomb and race out. We very much hope that they can wait until we are with someone who loves us before giving this kind of news.
Every day I hear stories about poorly delivered bad news. Yesterday I heard at least three: a woman who had a hysterectomy, never anticipating cancer, who awakened in the recovery room in the middle of the night. Her surgeon had gone home, and the nurses were not permitted to say anything. She didn't have her phone (had not anticipated the larger operation and being admitted, so had sent everything home with a friend) and had to wait through sleepless hours until dawn, borrow a nurse's phone, and call her sister in DC. Her sister had talked with the surgeon and her sister was the one who told her she had ovarian cancer.
Second story: A woman who had always been in excellent health, began to have shortness of breath, was diagnosed with pneumonia and put on antibiotics. When she continued to get worse, her son brought her to the ER where she had a scan. Again, while she was alone, a doctor whom she had never seen before, came in and said something like: "I am about to hit you with really bad news. You have ovarian cancer, and it has spread." Then he turned around the left the room.
Third story: When she went for her annual mammogram, it was recommended that this woman have an ultrasound. She knew that sounded like trouble, but no one said anything. Silence all around. After the ultrasound, the tech shook her head, said nothing (although asked several times) and walked out. Five or so minutes later, another tech came in, seemed surprised to see her and told her to get dressed and go home. When she got home, there was a message on her voice mail that she had what looked like breast cancer.
There seems, to me, to be no excuse for any of these things. The first two incidents happened at my hospital where we try really hard to be kind and attentive and prevent interactions like these. I hate to imagine how bad it gets at institutions where the culture is not so gentle.
From Medscape comes this article about teaching doctors to do better. I would also add that I think we, patients and families, can help with this effort. When we are given bad news, or sometime later, we can give some feedback. It is great to say: "You know, when you had to tell me that the cancer had recurred, it was terrible, but you were very kind.", and it is even more important to say: "When you had to tell me that the cancer had recurred, I was alone, and you did not sit down or spend any time with me. You made it even harder than it had to be."
Delivering 'Bad' vs 'Serious' News to Patients
No normal person likes to deliver bad news even once, let alone repeatedly. What sets medicine apart from most other professions is that it's an unavoidable part of the job. This doesn't mean that doctors ever get used to telling patients that their lives are about to change for the worse. Most never do. They recoil from it.
"Doctors go into medicine to help people do better," says oncologist Anthony L. Back, MD, a professor at the University of Washington and the Fred Hutchinson Cancer Research Center in Seattle and coauthor of Mastering Communication With Seriously Ill Patients:
Balancing Honesty With Empathy and Hope (Cambridge). "They don't like making people feel bad. When they give bad news, patients look glum, start to cry, or start to withdraw, and the doctors think instinctively, 'I have done not a good thing for this patient. I have made them depressed. Now what do I do?'"
Oncologists wrestle with this burden more than most other doctors. One survey of
oncologists found that 60% of the respondents delivered bad news to patients 5-20
times per month, and 14% did it more than 20 times per month.