Delivering bad news: Don’t pass the buck

Delivering bad news: Dont pass the buckWhen I was a fellow, part of our training involved doing consults for patients, most of whom had just learned they had cancer or recurrence of disease. These consults were never easy, but the importance of sitting with someone who had just learned of their diagnosis was an integral part of learning the medicine and art of oncology.

Even after many years, one call stays with me. It had come from an intern on surgical service who had called from a post-anesthesia care unit (PACU). The request was to meet with a patient who had just undergone exploratory surgery for a planned Whipple procedure. The surgery had been aborted because the patient had metastatic disease, discovered when they first entered his abdomen.

“That sounds terrible,” I said. “How did he take the news?”

“He doesn’t know. He hasn’t even woken up from anesthesia yet,” he replied.

I remember being taken aback. “Wait — so you want me to talk to your patient about his diagnosis of metastatic pancreatic cancer, and he doesn’t even know he didn’t actually have surgery?”

“Well, my attending wanted me to call you to make sure you saw him as soon as possible.”

“That’s fine, but I am pretty sure he didn’t mean before the patient had ‘woken up,’” I said. “Why don’t you call me back after your team has met with him and his family, told him that he didn’t have the surgery as planned, has stage IV pancreatic cancer, and what that means from your point of view. I assume he’ll be here tomorrow and I will see him then. I am not seeing him in the PACU, and certainly not while he is just waking up from anesthesia.”

At the time, I had bristled because it seemed to me the intern was “passing the buck,” assuming the delivery of bad news was the job of the medical oncologist. I suspected that was not what his attending had expected and that the intern was just being expedient. Instead, I had hoped that the patient’s attending wanted to be sure the patient was seen before discharge, so that his care could be appropriately coordinated. Fortunately, this latter scenario turned out to be the case.

When I think about it now, I realize that incident taught me something important — the value of a primary doctor-patient relationship, including the delivery of bad news, discussions about goals and preferences, and issues related to changes in treatment, including advance-care discussions. It was yet another watershed moment for me as a fellow, and one that has served me well.

This experience came back to me recently after an exchange with my own staff about a patient who was new to our practice. She had an advanced cancer and had come to us after she had progressed despite multiple lines of treatment. During our first visits, I had reviewed how serious her disease was and that any treatment would be palliative, not curative; and that I believed that one day she would die of this cancer. Although I was sure she was “hearing” me, it was only after multiple visits that I felt she was actually “listening.” But with each visit, I felt we were developing a clearer understanding of what her situation was.

After one such visit, a member of my team approached and asked, “Don’t you think she needs a palliative care consult?”

“Well,” I said. “I really hadn’t thought about it, but why do you think she needs palliative care?”

“I just think someone needs to talk to her about her goals and preferences. She should know she’s dying.”

This took me aback and I remember feeling angry at this suggestion. Looking back, my reaction was similar to the one from the PACU that I had so long ago. But in this, I was the one being asked to refer a job that was mine to do to someone else. But, hadn’t I been honest with this patient? Already told her how serious things were? Was it not clear to my staff that I was in the midst of those discussions on goals and preferences?

It took me a while, but I realized I had a visceral reaction to this suggestion because there seemed to be an insinuation that the “hard discussions” were no longer my responsibility. And I wondered, when did it become the job of the palliative care clinician to do this?

Palliative care has become a critical component to the comprehensive care of patients with advanced disease, and its benefits in those living with cancer have been documented in several randomized trials. Patients involved in palliative care early on in their illness appear to benefit in terms of both the quality of life and survival. As such, palliative care embraces the comprehensive care for our patients — it is attention to the physical, psychosocial, emotional, and spiritual issues of patients and their caregivers. Having the palliative care team available for my patients has improved their lives. Indeed, having them involved in the lives of my dad and my best friend made me even a stronger proponent of their involvement.

However, I remain concerned that the hard parts of oncology will be ceded to my palliative care colleagues. That the delivery of bad news, discussions of prognosis, and end-of-life discussions will be things that we, as oncologists, no longer need to do — we can just “call a consult.” Taken to the extreme, I worry that our residents and fellows will learn that they don’t need to address these issues either, because specialists are available to do the tough work for us.

This is something that we must avoid. Oncology embraces the patient’s care from the time of a cancer diagnosis to the end of their lives. It has been a privilege to care for patients during the trajectory of their illness, and some of the most poignant times in my career has been spent at the bedside of my patients as they left their lives, surrounded by their friends and families, or in the last few visits where discussion was not concentrated on the next treatment, but on the next few days, weeks, months. In my mind, to relegate that discussion to palliative care clinicians was as big a disservice as having a medical oncologist deliver bad news to a patient just waking up from surgery.

We have relationships with patients, mostly formed in the context of significant distress. Our patients rely on us for honesty and the best medical care, and that includes when things don’t look good or go as hoped. While I continue to advocate for the early involvement of our wonderful palliative care team, I feel one thing must be clear. As with any consult, we should specify what it is we are seeking from our palliative care team, and what role we would like them to play in the interdisciplinary care team for the most benefit.

I was again reminded about this recently, as I discussed a patient nearing the end of life, who had been admitted to the hospital. After hearing about my patient, including the circumstances of this admission, her prognosis, and my concerns, my colleague in palliative care (whom I had called in as a consult) asked quite simply, “How can we best support your patient, family, and your team?” It was perhaps the most valuable question and exchange I had that day, and ultimately, it framed the place of the palliative care clinician as a partner in modern oncology care.

Don S. Dizon is an oncologist who blogs at ASCO Connection, where this article originally appeared.

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