Consult Skills 3: Being Good at Bad News
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 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
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.
– 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
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!
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
Time, place and lack of interruptions are a must
Best advice – “say what you need to, then shut up”
Too often we mumble on, trying to give options, explain and alternatives – whilst patient is still ‘stuck’ at the news
Actually, this is part of my work I enjoy – I always thought that time in both critical care and palliative care was formative – both rotations to learn a straight-talking, no nonsense and ‘real’ experience without euphemisms…
And patients receiving bad news deserve a straight-talking honest and empathetic doctor.
That is all
I had this a few days ago; weight loss, sweats, mildly obstructive lfts. Did CT- liver mets++. Very sad. Felt I should just tell her even though in a cubicle in ED. Wasn’t sure anyone was going to talk straight over Easter w/e.
Also offered to come back after news sunk in and said bye at the end of the shift.