Delivering Bad News, Redux

Photo: Pink Sherbet Photography

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…so 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.

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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?
  6. 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…
  7. 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.
  8. 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.
  9. 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:
  • 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.
  • 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.
  • 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.

Finally, 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 Week: Why We Must Actively Pursue Happiness

19 comments to Delivering Bad News, Redux

  • Wow. You really touched some nerves with this one, Alex. What a wonderful post.

    I want to comment on #8—express your commitment of support. My father is 85 and in failing health. He is of the “stiff upper lip” generation, a man who didn’t think he should “burden” his children with his “aches and pains,” and who would never discuss anything as personal as his health problems or his financial state. He kept telling others how he wanted to leave “a little something” to his children (who are all better off financially than he is!) and wouldn’t discuss any of it with us until the day I told him that we don’t care if he leaves a penny—that we want him to enjoy the best quality of life he can for as long as he can, and that he should spend his money on himself. Suddenly, he was a fountain of information—because, I believe, he suddenly realized that he has support from people (his children) who love him. In the last few months he’s also been more forthcoming about his health issues, too, which leads me to #9, make a plan. My dad hasn’t had a very good relationship with his children over the years, but as you say, “People who choose to die with secrets often leave wounds in survivors that never heal,” and I for one am glad we are all working to repair those wounds. I just hope we have enough time left.

    Thank you for a very thought-provoking post.

  • 001mum

    If I may?

    Tone of voice and body language can have a huge impact. It’s “old stuff” but the arm crossing habit and leaning away are terrible habits. Direct eye contact is #1 in my book.

    When my mother-in-law died, the resident had no idea what had happened. He tried to come up with a solid reason and I told him if he didn’t know right then to say so. He was so relieved. She had been on peritoneal dialysis for 6 years and never, ever had an infection or any problems. Then a slight first infection, so an extra 24 hours on dialysis and “oopsie” a cardiac arrest. Her nephrologist was due to leave for a conference within a hour of her arrest, but he cancelled and came back to the hospital. What a beautiful man. My dad died 4 days later of a ruptured AAA. He knew he had one and declined the Rx.

    Touch *if accepted* says more than words.

  • Jane

    I am as astounded by your compassionate and comprehensive approach to this important aspect of medical care as I was by the arrogance and callousness of the residents I encountered while my husband was dying. I know there is am almost overwhelming amount of information to learn in medical school, but this topic should be thoroughly addressed if a physician is to truly “first, do no harm.”

  • helen

    My father died of congestive heart failure 3 years ago. Twelve years earlier he had bypass surgery at which time he was told that he was hanging by a thread and that the bypass would probably give him about 10 years. So after the 10 years had come and gone and he started to have heart problems, he knew he was on borrowed time. He always asked how much time he had left. He never got a straight answer and was usually told something on the order of “lets take one day at a time.”

    I don’t think this was a bad response. As you said hope is important. Almost every day he would say he was getting better. He wasn’t but nobody had any reason to tell him otherwise. He also said he was not in any pain. He continued to walk, shorter and shorter distances, and he needed to rest often but getting out of the house and taking his walk really seemed to give him a lift.

    I do have one suggestion for you. I like that you tell your patients to write down their questions and that you tell them you will answer them. However, I would suggest you go one step further. Offer your email address. Don’t respond to the emails after office hours but if you find a chance during office hours, sometimes an email response can be handled very quickly and you can get back to your patient sooner. Alternatively, maybe you can respond to text messages or both email and text.

    I don’t have a terminal condition. I have one doctor with whom I correspond by email and it works out very well for both of us.

  • Marcia

    I agree with the difficulty in presenting news of a situation that may have no cure but am disappointed that you made no mention of offering hospice services when treatment may not be effective, has run it’s course or the patient chooses not to proceed with treatment. Hospice offers them hope for comfort, quality of life, pain and symptom management and interdisciplinary services for patient and family. I have worked in hospice over 12 years (not currently) and my mother died on hospice while my father died while in rehab and rushed to the ER, intubated and attempts made to resuscitate him while he had a DNR in place. I know your focus was on how to tell difficult prognosis but believe hospice is often overlooked by many doctors who view this as a service when a patient is dying rather than when there is a terminal diagnosis and a 6 month prognosis.

    Marcia: I’m a great believer in the value of hospice and have referred many a patient to it. Thank you for making this important point.

    Alex

  • Kimo

    This post is filled with great advice and clearly comes from the very best place in your heart. There is one statement, however, that I would disagree with, if only for myself. You stated, “I’m convinced that nothing lessens the quality of life more than living it without hope.” I happen to have a terminal illness, an extremely rare cancer. No one is devoting a minute or a penny to researching it, so, no, I have no hope that a fantastic new drug might be just around the corner for me. I have zero hope that I will be some unexpectedly unique example of someone who survived this disease. I realize that other people feel differently when confronted with a serious illness. I will die relatively soon, and that’s okay. I still laugh every day and am as happy as before I was diagnosed, although the conditions of my life have certainly changed (no longer able to work, etc.). I don’t feel that I have to believe I will be an exception to be happy right now. Everyone dies eventually (although perhaps not quite as young as I am, diagnosed in my 40s), and I have so much love and support—why wouldn’t that be plenty?

    Kimo: I actually discuss the doubled-edged sword that hope can sometimes be in my book. I wish you continued strength and happiness.

    Alex

  • El Phoenix Farris

    This is an outstanding article written with both clarity and compassion. For me, the hardest thing when delivering bad news is finding a way to stop talking—which you address very well up above.

  • This brought back so many memories that still make me tremble. So many stories. Such sadness.

  • Alison

    Hello, I often think when I read your blog that you would be the kind of doctor I would hope for if I ever got sick. My boyfriend and I sat on the sofa last night reading your book to each other. Thank you for writing and for your blog, which anyone can read. It is a gift.

    Alison: You’re so kind to say so, thank you.

    Alex

  • Marcella

    Thank you for recognizing the importance of caring. I’ve had chronic neck pain for the past three years and have seen all sorts of doctors. Finally, through the recommendation of my boyfriend who is a neurology resident at the University of Miami, I went to see Dr. Patin, who is known for being the “best” pain doctor in Miami. My boyfriend raved about how friendly he was, and my own neurologist said he is known for being compassionate. My father joined me for the apt. and by the third apt I left in tears. He simply didn’t care, and he made it evident by not listening to me, or cutting me off mid-sentence. And when someone is so highly recommended, the least you’d expect is that they care.

  • Ellen

    I don’t know if this is true for everyone, but for me personally, regarding #3: I would rather be told “the test shows cancer” or “this is cancer” rather than “you have cancer.” The “you have” can be jarring and can sound almost like an accusation, even for minor, non-fatal conditions. If the diagnosis is something more serious, it can really pack a jolt. The only exception I can think of would be if someone continues to be in denial about their illness, in which case saying “you have such-and-such” may be appropriate.

  • Betty Segal

    It has been almost 50 years, but I still remember how my 12-year-old son and I were given the bad news about the lump on his testicle.

    At my son’s annual physical on a Friday, his pediatrician discovered the lump, discussed it with his partner, and then said he would like it to be seen by a specialist. He didn’t make it seem like an emergency, and I was not alarmed.

    On the following Monday, we were given an almost-immediate appointment with the specialist who, after examining my son, met with us in his office. He turned his back to us, picked up the microphone to his recording machine, and dictated his case report, describing the lump, saying that it was probably malignant, and that treatment would be the removal of the testicle. He then turned to us and began to describe how we were to go immediately to the hospital next door for surgery the next day to remove the testicle.

    I was appalled that anyone could deliver news like that in such a callous way. I later reported it to my son’s pediatrician and suggested that he not refer patients to that specialist. The pediatrician explained that although the specialist lacked finesse in his bedside demeanor, he had the gentlest hands of any available surgeon, and that he felt that was the more important criterion. That made sense to me, and I later sent my brother to the same specialist for prostate surgery.

    (End of story: The lump turned out to be a rare, nonmalignant, cyst.)

  • Tara

    One of my favorite books is Rachel Naomi Remen’s Kitchen Table Wisdom, and she quoted one of her patients who said that his doctor’s love was a huge part of his treatment. Compassion and caring is the greatest gift we can give to each other, especially when there is not much medically that can be done.

  • rdp

    Thank you for trying so hard, Alex. I am an occasional poster of questioning and sometimes critical comments to this site, and am guilty of failing to say as often how much I value your dedication to thinking through (and not just mentally) all the issues you address here.

    We are lucky to know you—even just as readers!

    Wishing you a happy Hanukkah and peace and goodwill throughout the holiday season and always.

    rdp: So nice of you to say, thank you. I always welcome and enjoy your stimulating comments. Keep them coming!

    Alex

  • Spot on and sadly, not too well taught in our training.

    The object of hope I think is important. For a terminal disease like cancer where the odds of recovery are worse than the lottery, false hope of a cure can be cruel. It can encourage denial and keep the pt from truly addressing end of life issues—how one wants to die, saying goodbye to loved ones, what last things in life does one want to experience. So I try to foster hope in those things which still leaves the pt something meaningful and worthwhile to hold to.

  • Karen

    Alex,
    Thank you for reminding me there are still individuals in our healthcare system who honor people as the individual human beings they are along with the concept of the circle of life…birth/living/death. Your words are always so thoughtful, as well as thought-provoking.

  • I can relate in many ways at an animal level (is that better than losing a human?) and never felt really successful explaining why a horse needed put down or why an animal died unexpectedly. It ruined my day and every one else’s I am sure, but the next day you get up and motor on. I do not envy you and thank you for taking the time to think about it.

    My own horse died recently in 30 seconds in front of me probably from an aortic aneurysm. It was quite a shock, but like you after having struggled with 40 years of slow drug out deaths it really was a blessing in some ways.

  • Thank you for this wonderful post. It should be required reading for every health care provider.

  • Cecilia

    I was going to read this. But I couldn’t. I want to be a doctor myself. But I want to have the chance to figure out these things on my own. I think it will make me better. … Right?

    Cecilia: I’m afraid I can’t agree. Would you say the same about learning medicine itself, that you will be a better doctor if you figure out how to treat illness on your own? Why not learn from others’ experience? You can only figure out what works for you by doing, but why not first try what others have found to work for them?

    Alex

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