I would like to give some tips to younger doctors regarding how to tell your patient that he is going to die. Your approach should also incorporate your unique personality, as well as published literature and other resources.
For your first case, watch someone more senior tell the patient. See what you think worked and what could be improved. When it is your turn, make sure to have all your technological ducks in a row. Do not tell someone they have cancer, for example, until you have the biopsy back. You can find prognosis aids now for many disorders, though they are somewhat imprecise. Learn the skill of having and showing both humility and assuredness.
Do not wait too long to tell the patient, but make sure you set aside sufficient time. Tell them in person if possible, not over the phone. If the patient is in the hospital, make sure it is not during rushed morning rounds — come back later when you have more time and when other family is present.
When you go into the room, greet the patient and whoever is there. Often a whole crowd awaits the announcement. Shake everyone’s hand and introduce yourself. This is not the time say, “My name is Troy.” You need to say, “I am Doctor ____” (use your last name). This conveys that you are a professional and that you take these problems seriously. Sit down if at all possible. This eases fears and shows your investment in quality communication. Bring an extra chair in if needed. Studies show that when doctors sit down, their visits are not lengthened.
When greetings are complete, say what you need to say. There is no need to talk in circles. You can say something like: “I am sorry to have to tell you, but your biopsy shows cancer” or “It looks like your father will almost certainly not survive this hospitalization.” Simple, clear statements are best. Avoid slang and crass language, even if others in the room use it. If the prognosis is very unclear, then you can say something like: “Mr. Smith is not doing well medically. I would not be surprised if he passes within a few weeks or months.”
After giving the bad news, be sure to pause. This may seem unnatural or surreal, and it is, but the situation calls for it. Staying silent can be difficult. You must decide in advance to use pauses and then discipline yourself not to fill up the space with words, especially if you are the talkative type.
After pausing, add necessary details. Tell the patient what kind of cancer it is or what is known about his disease. When things are unknown, use language that reflects this. With recent research to back you up, you can say something like: “It has been shown that doctors are not that accurate in predicting how long someone has to live.” If you are successful, you will convey that on the one hand, it looks like death is near. But on the other hand, there are many unknowns.
Ask if there are any questions. They will soon enter into the grieving process, and it may become more difficult to get information to them once they are in the throes of anger or bargaining. Is the oncologist coming? What kind of follow-up will the patient have? An outline without too many details here is appropriate. If you do not know how to answer a question, simply tell them that, and let them know who might be able to.
Remind the patient and the family of priorities. Is there someone they need to tell? It usually helps the patient to talk to family and friends. If death is imminent, ask if there is those who would want to come in from out of town, so that they can be called.
Everyone experiences some denial. It is the first of several stages of grief. Anger is next, and not uncommon in this setting. You may also see some bargaining, but usually people in this sort of meeting are in a sort of emotional shock. The main thing to understand is that the stages of grief are normal. Your job is to convey information and to allow people to experience the specific stage that they each need to be in at the time.
Do not take someone’s anger personally. Do not be surprised when patients and family members accuse you of one more infractions in terms of care or diagnosis, since you are the available target. Their world is being overturned. For this visit, limit your rebuttals, focus on giving succinct information, and listen patiently.
Wrap up the visit with a list of resources and next steps. Tell the patient you will call the oncologist. See if the family needs help from the social worker. Would the patient like to talk to a chaplain? Before you leave, touch the patient. Be situationally appropriate, which usually means shaking his hand or touching his shoulder. Hug him back if he hugs you. Be culturally sensitive, but touch. Hold the patient’s hand for a moment and look at him in silence. It may make you uncomfortable, but gets easier with practice.
After you leave the room, let the nurses know about your meeting. In the inpatient setting, they have more time with the patient, and want to be informed to do their best in caring for him.
This kind of news is difficult to receive, but it is also difficult to give. It does get emotionally less challenging with experience, but you do not want it to become so easy that it no longer bothers you at all. So the last step in this process is something every doctor needs to do: care for your soul. Realize that shallow distractions such as alcohol and Netflix are simply not going to be enough for most people. This kind of work is done best when the inner spiritual life is cultivated and attended to.
Paul Bunge is an internal medicine and palliative care physician.
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