We have a great job, but sometimes it sucks! Forget the annoyance of shift work, the heirarchy and long hours – for me the worst part of the job is when we find something nasty, or have a poor outcome – giving bad news to nice people is never easy. Why? well it goes back to the type of people we medicos are ‘on average’. We are usually pleasant, we like to make others happy, ease suffering and get good results – this is one scenario where none of these is likely to occur. So how do I think about “giving bad news”?
There are a lot of teachings out there, and anyone who has done any GP training will have had this drilled into them throughout their training. In Australia you can be guaranteed that you will get a “bad news” case on your fellowship clinical exams. So here is a case and my “rules” for being good at bad news.
You are in your office checking your emails when the radiographer calls you to say she needs help….She has been doing a 19/40 anatomy US on a nice young lady with her husband watching to catch a glimpse of a face or a gender. All seemed well, until the radiographer realised that this baby had no brain – it is anencephalic. It is a small town – the radiographer plays netball with the expecting mother and cannot hold her poker face. She stops scanning and tells her she is going to find a doctor to get a second opinion. This is when she called you.
If you are like me – you know what this means, but the exact logistics of dealing with anencephaly are well beyond my scope of practice. I need help and will be calling my local ObGyn for advice. However, the young couple are aware that something is wrong. You need to talk to them and provide counsel – so how to do this in real terms…
Here are my rules:
This will depend on your own knowledge and the scenario in question – but before you walk in the room you need to have a clear understanding of the problem, the management and prognosis.
This might mean doing some research or asking for specific specialist advice – but you have to know. If you are unsure – you know that will be the first question they ask – and you need to be able to provide clear and concise counselling. This is not the time for ummm or errs – the patient needs clarity and a direction. Any vague responses will likely provoke anxiety and confusion in a person who is already having the worst day of their life.
You do not need to have encyclopedic knowlege – but you should be able to provide clear and accurate information now, today! So take a few minutes – call someone who does know and get the facts straight in your noggin
This conversation is going to take time – and it is the most important thing you will do today (this year?) so create plenty of time. Hand your phone or pager to a colleague. There is nothing worse than feeling time-pressured or being interrupted for trivial problems in the middle of this crucial dialogue. This conversation will be stamped into your patient’s memory for years to come so make sure you do all you can to make it quality. If you cannot make time in the day – then plan to see the patient at the end of your day / shift – that way you are free to take as long as required without the pressure of the waiting room etc.
You need uninterrupted privacy. It is really hard to predict how any individual will react to the news you are giving them – so do it in a priavte room, away from traffic or onlookers. The curtained bay of an ED cubicle is not the place to do this! I once saw a doctor give a trisomy 21 result through the bullet-proof glass of the triage window – that is just wrong.
Beware that some folks will have a dramatic response – crying is normal, butI have seen a few people have syncope and prolonged, almost catatonic responses – so it is helpful to have a bed or somwhere the patient can lay down if the need arises.
It would seem obvious, but not always done. You want to ensure that the patient brings along all the people who they need – spouse, parent, children etc. If you get this wrong there are a few possible problems. You need to ensure the patient is happy for those people to be there from a confidentiality POV.
– Talking to somebody alone is not advised – they need a support person to help them through and share the experience. Sometimes even to get them home safely.
– If an important family member or person is not there – they will likely get the message indirectly and inaccurately – this will lead to tension, misinformation and sometimes anger
You need to decide the words you will use up front. You need to get the message across in clear, simple, unambiguous language. It is human nature to want to hear things in a positive light – so you need to use clear language to avoid any misunderstanding.
The use of subtlety or pleasant euphemism is not allowed – that is about you wanting to avoid the unpleasant nature of the conversation. In order to do this right you will probably feel uncomfortable – that is your problem – not the patient’s!
Once you have given the patient / family the information you need to be quiet. Usually you are delivering life-changing news and it takes at least a few minutes for people to process and begin to comprehend what is happening. Talking at this point is unhelpful at best! Let them process and just wait – when they are ready they will ask you what they need. You may feel uncomfortable with a prolonged silence, but wait, resist to urge to add info or interpret their response.
It is well studied that patients recall very little of the data received in these scenarios. They remember the demeanour of the doctor, but often not the simple things – like what happens next. So before you start this consultation – have a clear plan / referral /investigation or next appointment prepared. The patient will walk out in a haze often – so giving them a firm “next step” is vital – avoid open-ended time frames and the “I’ll get back to you” strategy. I usually plan to see them the next day – they usually have a lot of questions. In reality this is not a ‘one stop’ consult – it is the start of an important therapeutic relationship.
OK – that is my simple approach to the delivering of bad news. Do you have any pearls or strategies that you have found useful in your practice? Let me know