The massive magnets of the MRI radiate fields through her brain, scanning veins, arteries and every millimeter of cortex. Grey and white matter, containing all she is and all she ever will be, identified, cataloged, mapped. Two centimeters under the front of her skull, just to the left of center, there is an abnormality; a one centimeter mass surrounded by swelling. The lung cancer has spread, metastasized. Really bad news.
A patient, whom I have known for many years and consider a friend, asked me recently, “How do you get ready to give bad news?”
She meant this question two-fold. First, how do I organize the information I am about to reveal and second, how do I steel my emotions for the difficult conversation ahead? It is an important question and the answer is key to successful relationships between doctors and their patients.
First, it is critical when a doctor has bad news, not to delay in telling the patient. As I instruct my patients, “if you have had a scan and I have not called you, it is not that I do not have the guts to call, it is that I have not seen the scan.”
Patients worry and worry and worry, and every second of delay makes the news to come worse and wears at the relationship between doctor and patient. Take a deep breath, get it done.
When I first went into practice, my senior partner gave me a fantastic piece of advice. He said, “Whenever you are going to take, be ready to give.”
What he meant was that when a doctor gives bad news, he is taking away choice, the image of health, and perhaps life itself. To learn something is significantly wrong with your body is to lose certain possibilities for the future. Bad news given by the doctor can take away hope.
Thus, key to giving bad news is to prepare and be ready to answer the question, “Doc, what do I do now?” It is a mistake to simply walk up to a patient and say, “sorry but the cancer has come back, I’ll get back to you.”
Rather, the doctor must consider what comes next. This next step may be complex and potentially curative, such as “we need to get a PET scan, a biopsy and to have you see Dr. Smith, who is a surgeon.” Or the plan may be more supportive, such as, ”Well, when a cancer comes back like this is not curable, but this is how we are going to control your symptoms.” Perhaps the plan is just a family meeting. The doctor needs to have considered the next step before he walks in the exam room or picks up the phone.
Bad news should be given in a place of privacy and as another set of ears is invaluable, whenever possible there should be at least one supporter with the patient. I detest giving bad news on the phone, but when it cannot be avoided, I try to set it up that phone conversation beforehand. Thus, if I am ordering a test whose result I am forced to give on the phone, I say, “now when I call you it is likely to be one of two results, and this is what that will mean.” Still, scheduling an immediate office visit after the test is performed, is a better approach.
The next steps in giving bad news are patience, time and silence. Once the bad news is said, most patients shut down. They lock on the bad news and nothing else the doctor says at that moment is heard. So, no rush, take your time. The Inuit people of Alaska routinely sprinkle long periods of silence into casual conversation. It is a good time to practice that technique. The doctor needs to resist rushing ahead to explain the plan he has prepared. Sitting together, crying or hugging if appropriate, or just allowing the patient to focus, is necessary. Many patients need the bad news repeated, which is usually obvious in their response and questions. Human beings have tremendous powers to cope with adversity, but we are not unfeeling supercomputers: we need time.
As the patient and doctor move forward with the conversation, there are two key elements for the doctor. Listening and teaching. The physician needs to listen carefully to what the patient understands and their needs. If the doctor goes off on a wild tangent, such as “we are going to start quadruple-drug-massive-intensive-ablative-horrendous chemotherapy tomorrow,” and misses the one-year-old birthday party next week, the conversation will be a disaster.
Often a physician can help the patient and family with not only education and information, but also suggesting that a second opinion at this critical moment in a patient’s medical course is never a bad idea. As I tell patients, “the worst thing that can happen with a second opinion, is that we all learn something.” No matter what, reeducating the patient about the disease process and on choice is vital and such teaching is at the core of the physician’s profession.
This takes us back the vital question asked by my friend: how does a doctor prepare emotionally to give bad news? I think the answer is that the physician prepares by getting ready to do his job well. If he does a good job delivering the bad news, than he has helped the patient and family move forward in a difficult time of their lives. Done well, this is satisfying and important work. While at times it can be sad and even tragic to work with patients who are experiencing overwhelming health events, if the doctor can guide them through such times, then some element of suffering can be avoided. The healing of suffering, giving the chance to cope and preserving hope, gives every doctor peace and solace.
James C. Salwitz is an oncologist who blogs at Sunrise Rounds.