Delivering Bad News

hands

Photo: five2b4u

My heart began pounding as I listened to the sound of the dial tone in my ear.  After three rings a woman answered groggily and uncertainly, “H-hello?”

“Mrs. Peterson?” I asked.  My voice trembled slightly.  It was 2 a.m. and I’d awakened her from what I imagined had been a troubled sleep.

“Yes?”

“This is Dr. Lickerman.  I’m calling from the hospital.”  I paused.  “I’m calling about your husband.”

There was silence.  Then a breathless, “Yes?”

“Mrs. Peterson, I’m the resident on call taking care of your husband.  Your husband—your husband’s suffered a complication.  You know the heart attack he came in for was very serious.  A large part of his heart had stopped working.  Well, Mrs. Peterson, I just don’t know how to say this to you but…your husband passed away tonight.  We tried everything we could to save him but there was just too much damage to his heart.  It just couldn’t keep pumping blood.  I’m…really sorry.  I don’t know how—I’m just really sorry.  I wish I weren’t telling you this over the phone…”

A few more minutes of silence passed, and I realized she was crying.  “I understand,” she said finally.  “Thank you.”  Then she asked,  “What do I do now?”

Relief coursed through me.  “There’s a hospital administrator on the line—”

“Hello,” the hospital administrator said gently.

“—he’s going to explain everything you need to do.”  I paused.  “Mrs. Peterson, I am just so sorry…”

“Thank you,” she said quietly.  When I hung up I found my hands were literally shaking.

I was a first year resident, and this was the first time I’d ever had to tell a family member a loved one had died.  It had happened in the middle of the night so I’d had no choice but to deliver the news over the phone.  Not only that, but because I was covering for another resident and had only met Mr. Peterson (not his real name) that night after his heart had stopped and I’d been called to try to resuscitate him, his wife ended up hearing the news of his death from a total stranger.  It was an experience I will never forget.

DOING IT BETTER

In the years since then, I’ve had to deliver that kind of news to families a score of times and bad news of a slightly lesser magnitude hundreds of times.  In all honesty—and contrary to the popular saying—it has in fact become easier, partly because I’ve learned to do it better, I think, and partly because the more you do anything the less it stirs up the emotion that initially accompanied it.  What follows is the approach I’ve developed over the years to deliver bad news in the most compassionate manner possible.

Prepare yourself to feel badly. Doctors enter medicine with the hope of making patients feel better.  However, when delivering bad news, that’s not what happens.  No matter how people feel before I give them bad news, afterward they always feel worse.  If I don’t recognize this as normal, that working hard to make people feel good about bad news is not only counterproductive to the grieving process but potentially deleterious for our doctor-patient relationship, in the long run I’ll add to my patients’ pain rather than diminish it.

Set the context. When delivering bad news of any kind, providing the recipient time to prepare themselves can be helpful.  My attempt to do this with Mrs. Peterson was clumsy (“You know the heart attack he came in for was very serious”), but my intent was honest:  I wanted her to realize I was about to tell her something awful.  The phrase “brace yourself” carries more than a metaphorical meaning in this context.  Psychologically, even a single moment of preparation can mute the pain of hearing bad news, if only a little.

Deliver the bad news clearly and unequivocally. I don’t say, “There’s a shadow on your chest x-ray” or “You have a lesion in your lung” or even “You have a tumor.”  I say, “You have cancer.”  The temptation to soften the blow by using jargon is surprisingly powerful but extremely detrimental.  At best, it delays the patient’s understanding of the truth; at worst, it promotes their denial of it.

Stop. When a person receives bad news, they always have some kind of reaction.  Some cry.  Some get angry.  Some sit quietly in numbed shock.  Some refuse to believe what they’ve been told.  My job at that point, however, isn’t to clarify, mollify, restate, or defend the diagnosis or myself.  My job is to respond to their reaction and help them through it.  I vividly remember the first time I had to tell a patient and his family he had lung cancer, some time after my late night call to Mrs. Peterson.  I came into the room to find ten or so family members gathered around my patient’s bed.  I set the context, I delivered the news clearly, and then I launched into thirty minutes of clarifying explanation.  When I finally paused to take a breath and to allow my patient to react to what I’d told him, he only looked at me with a sad expression and mumbled in a subdued voice, “I thought I had more time.”  He hadn’t, of course, heard a word I’d said after I’d said the word “cancer.”  The only person I’d been attempting to treat with my soliloquy had been myself.

Ask for questions. Once a person’s reaction has run its course, or at least paused, I always ask if they have any questions.  Often they don’t, at least at first.  But often they do.  I answer them all as honestly and directly as I can.  Surprisingly, or perhaps not so surprisingly, people rarely ask the questions doctors dread most:  Is this terminal?  How long do I have?  How likely is the treatment to cure me?

But sometimes they do.  When patients ask if their illness is terminal, I tell them the truth:  the percentage of people who survive any illness breaks down into two groups, those who survive and those who don’t.  The percentage may be dramatically and tragically skewed toward those who don’t, but I emphasize that no one can predict into which group any particular patient will fall.  One thing I’ve learned in my years of practice, both as a doctor and a Buddhist, is that nothing is certain…

Never destroy hope …except for one thing:  if you destroy a person’s hope for a good outcome, they’ll suffer far more on the way to whatever bad outcome may be in store for them than if they’d had the opportunity to approach it full of hope.  Especially when the quantity of life left may be short, the quality of life becomes even more important, and I’m convinced that nothing lessens the quality of life more than living it without hope.  How do you prevent hope from failing when the outcome is so likely grim?  I have no ready answer.  I often make statements about the frenzied pace with which new knowledge and treatments are discovered and once or twice have even seen a new discovery make a difference in a person’s prognosis.  But often it’s what I don’t say that allows people to continue to hope.  It’s every person’s natural tendency to continue to hope even in the face of terrible odds, and whenever I believe I need to say something that risks interfering with their belief that things may somehow work out all right, I think very carefully before I speak.  I never lie, but neither do I automatically verbalize everything I’m thinking.  In general, I try not to enable false hope, but I always wonder if that does more harm than good.  I honestly don’t know.

Express your commitment of support. I always make a point to say to every person to whom I deliver bad news, “I will not abandon you.”  I am continually amazed at the level of relief this provides.  Just knowing there is someone in a position of confidence and authority who genuinely cares about what happens to them, who can explain the things that occur during the course of their illness and simply be available to them, is enormously relieving to most people.  I also add, if it applies, “I will not let you suffer.”  Adequate training in pain relief is woefully sparse in most medical schools and residency programs, but the technology exists to mitigate, if not completely control, the pain of most (though not all) illnesses.

Make a plan. I always give patients a series of instructions at the end of a visit in which I’ve delivered bad news.  I tell them:

  1. Write your questions down. Once the shock of hearing the bad news wears off—usually after they’ve returned home—many questions typically arise.  I promise to answer them all, either on the phone or at our next visit, which I always schedule before they leave my office.
  2. Tell your family. People frequently struggle with this, often thinking first of the impact their illness will have on their loved ones rather than themselves, and seek to insulate their family—or specific members of it—from the news.  I am convinced this does more harm than good in most situations:  it prevents damaged relationships from having a chance to heal and often creates more angst than it resolves, not to mention cuts off critical avenues of support.  People who choose to die with secrets often leave wounds in survivors that never heal.
  3. Prepare yourself for what comes next. It may be more testing.  It may be treatment.  It may be both.  It may be neither.  The last is the hardest to bear, I think.  At least while you’re engaged in treatment you’re doing something active, fighting the diagnosis in a concrete way.  Many people become inconsolably anxious once their treatment stops because at that point all they have left to do is wait for a relapse.

Follow up. Whether by phone or in person, I always talk with the person again within a week.  Often, the person will have made surprising progress in coming to terms with the news that’s been delivered.  The human mind has a remarkable capacity to adjust to tragedy, and in fact I believe begins to cope with bad news the moment it’s delivered.  Many people agree that the wait for bad news is almost worse than actually receiving it.  At least once you receive it—even if it’s the worst you feared—you can begin to take action to deal with it.

THE IMPORTANCE OF CARING

All of us will receive bad news—devastating news—in the course of our lives, if we haven’t already.  Studies have shown patients and their families remember the way bad news is delivered—the exact words doctors use, how they looked, and whether they seemed to sincerely care—for the rest of their lives.

Which is why every time I’m about to enter a patient’s exam room to deliver bad news myself I pause and remember Mrs. Peterson, a woman I’ve never seen or heard from since, but whose life I irrevocably changed in the middle of the night while she lay at home in bed without her husband next to her—as she would from that point forward—all those years ago.

NEXT WEEKLetter To A Widow

11 comments to Delivering Bad News

  • Pete

    Alex, a very meaningful article. I would hope that whenever I have inevitable serious medical news presented to me it would be done in such an honest,forthright compassionate way. In many ways that was the approach of the palliative care nurses who attended the last few days of my brother Rik’s life in Kelowna. Their prior experience and compassion helped me cope with that difficult part of life’s cycle. Rhea is fortunate to have you as her life’s partner.

  • Mike Lickerman

    Now that’s more like it!

    One thing that isn’t mentioned here is that when a person founds out they are terminal and doesn’t tell their family right away, they are depriving the family of time to adjust to the news as well.

  • Hope. I’ve been seeing that word thrown around a lot and it keeps popping up in my mind. Love is supposedly the greatest; however I think we underestimate the importance of hope.

    -Nate

  • Norah

    Alex, I agree with Pete, in that I would rather have an honest and compassionate delivery of a diagnosis than be left with vague intimations of possibilities. Our brother did not seem to accept the fact that he was dying and his wife did not ask the right questions, or was not told that Rick’s condition was terminal. To this day she wants to know why further treatment was not offered. Hope is necessary to live as normally as possible and to actively engage in treatment, but acceptance of the final outcome is to have a peaceful end.

  • The first step is to start.

    Difficult conversations require courage. They require accepting our own vulnerability.

    The clarity of death is a blessing because what to do next is more clearly defined. What to do when we lose a job or have been profoundly unhappy for more years than we can count presents a complex dilema.

    The first step is to start.

  • Hope is important in these things because you hear of stories where people have defied the odds and recovered from the unrecoverable—you just never know.

  • Sandy

    I’m in tears! That was beautifully written, Alex. What a thoughtful, compassionate man you are. I wish I had a doctor like you! (In fact my doctor moved and I’m without a doctor now – relying on walk-in clinics whenever I need one). Thanks for sharing your blog with me. It was very moving and thought provoking.

  • Judith

    Thank you so much for this article: I hope it is widely read in the medical establishment. I had to practically beg my radiologist to use the word “cancer” when I was first diagnosed. Because she used phrases like: “this concerns me,” “this is an irregular area,” etc. I had to force the reality: I had cancer. Once she spoke the word I actually felt relieved; however, at the moment of diagnosis, the last thing I wanted to do was to teach my medical professional how to deliver bad news.

    Judith: Isn’t it amazing how apparently well people can avoid naming unpleasant things by altering the words they use? My personal favorite (which unfortunately I hear my colleagues use all the time) is “this is in no way inconsistent with X.” The double negative, the passive voice, euphemisms—all ways we avoid confronting the truth honestly out of fear.

    Alex

  • redplanet

    Here’s hope: doctors don’t know as much as they think they do. I was diagnosed with an incurable, but not fatal, illness and my doctor yakked on about surgery, drugs, etc. He even told me to give my kids to someone to take care of. I shined it on. I went to a medical library and researched in texts and journals. Blech – they knew nothing. I went to the health food store. I asked a lot of questions. I learned much about using vitamins and herbs for my condition. I did a lot of thinking. And more research. I designed my own protocol. I am cured. If you don’t like the word cured then call it the 30 year remission. The last words of my board certified moron: “You’ll be back here on your hands and knees begging me for drugs.” I never went back but I always thought of that as I rollerbladed, hiked, biked, swam and had good sex over the years. I didn’t give my kids away, in fact I had another one eight years later. No one has an expiration date. Don’t give one to your patients.

    redplanet: I love the fighting spirit of your comment—and especially your last two lines!

    Alex

  • Bradford Kellerer

    In the year 2000 ,My wife was told she had Parkinson’s disease at age 54. The neurologist presented to us as: “Mrs. So & So, I have good news and bad news. The bad news is that you have the symptoms of Parkinson’s disease. The good news is that we are making great strides in treatment and will eventually effect a cure.”

    In a flash we went from horror to hope.

  • Lisa Fields

    Dr. Lickerman,

    My former husband was/is a minister. Having been a clergy wife who also has a social work/counseling background I often visited with members of our church when they were in the hospital. I can’t tell you how many times they would ask me to find out what was wrong with them and explain it to them.

    This was before HIPPA was implemented.

    If doctors or other medical teams had used “plain speak” as we Quakers practice, I believe this would have been beneficial. To not know or understand certainly adds to a patients anxiety level which in turn I believe can increase pain levels. It can be difficult for even the most centered person to admit they don’t understand what a medical professional is attempting to communicate.

    Thank you for your important work. I found your website due to a recent post from the NY Times.

    Peace be with you,

    Lisa Fields

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