How to Break Bad News
How do you break REALLY bad news? How do you tell someone that they’re seriously ill, or even dying? Find out how doctors learn and how they deal with the stress and trauma, for both their patients and themselves.
Breaking Bad News
By Chrissie Giles
I was 14 when I was told that Dad was dying.
I was sitting on the floor of our lounge. Mum said that she had some news. Sensing the worst, I fixated on the newspaper open in front of me, staring at an advert for German cut glass. It was cancer, in his pancreas, and he might only live a few more months.
They were going to try an operation, she told my sister and me to reduce the pain. As a nurse, she must have known that this was unlikely to work, but she knew her audience and didn’t want to overload us with information. She must also have known that pancreatic cancer has one of the bleakest outlooks, due in part to a lack of symptoms in the early stages. By the time you start to notice nausea, jaundice or weight loss, it’s too late to hope that it’s something less serious.
That night, as I wrote my diary, I could think only about how I felt. Reading it back now I wonder what it was like for my mum, still reeling from the news herself and having to tell the rest of us.
As a doctor, Kate Granger often deals with discussions of bad news and end-of-life issues. But there’s another reason the subject interests her. Three years ago, at age 29, she was diagnosed with a very rare and terminal form of cancer that affects soft tissue. She’s spoken and written widely about her experiences living with a terminal disease. She spearheaded the #hellomynameis campaign, to get people working in the NHS to introduce themselves to every patient they meet. She’s planning to live-tweet her own death.
Granger was diagnosed with cancer while on holiday in the USA. “I came up with some tough episodes of breaking bad news when I got back to the UK,” she says. “When I got my MRI results, I was told when I was by myself by a junior doctor who didn’t know what the plan was going to be.”
In pain and alone, she was told “without a warning shot” that her MRI scan showed that cancer had spread. “He was basically giving me a death sentence. He sorts of couldn’t wait to leave the room, and I never saw him again.”
Her experiences have shaped her as a doctor. “I think I was a fairly compassionate, empathetic doctor, but having been through all I’ve been through. When I came back to work I was just so much more aware of how body language is really important, how you think about the impact of bad news on an individual more than just viewing ‘telling Mrs. Smith that she’s got lung cancer’ as a task.”
The surgeon and author talk to Mosaic about end-of-life care, writing and how doctors can be better communicators.
I ask several doctors to share their experiences and the patients that stick in their mind. One remembers a woman who came in soon after Christmas. She’d been in and out of the doctor’s over the last nine months or so, with general symptoms that are all too easy to ignore: feeling tired, swelling. Then she had suddenly become jaundiced and short of breath, so a relative brought her into A&E.
It was one of those situations, the doctor says, where you pull the curtain back and immediately think, “This is not good.” “On very few occasions do you touch something and say, ‘This is cancer.’” When she examined the patient’s abdomen, it felt “rock hard.”
“She kept saying to me, ‘It’s going to be fine, isn’t it?’ And I’m saying, ‘We’ll do everything we can, let’s just do a few tests and figure out what’s going on.’ At that stage in my mind, I knew it was bad, but I still had to figure out exactly what flavor of bad it was.”
The woman was anxious to be home on New Year’s Eve to make a call to family overseas. But blood tests confirmed that she’d need to stay.
“She said to me, ‘Tell me the worst-case scenario.’ I looked at her. She looked at me. And in my mind, I was thinking, ‘She’s not ready for this diagnosis.’ Then her relative stepped in, and she said, ‘No, no, she means what’s the worst-case scenario regarding how long does she have to stay in the hospital?’
“At that moment, you realize that we all know exactly what we’re talking about, but we’re all accepting it to different degrees.”
Compartmentalisation seems to be important in coping – she mentions several times that bad news, death, is part of the job. “You have to be strong for the family. I can easily go back into the staffroom and cry my eyes out, but at that moment I have to be there, I have to be the hand to hold or the shoulder for the patient to cry on.”
The doctor speaks of the first patient she cared for, a man with metastatic prostate cancer. She was called into his room by his wife, and as she arrived, the man took his last breath. His wife broke down onto the floor in front of her. “At that moment, you have to say, ‘I’m sorry, he’s gone.’ And you kind of just has to suck it up and be there for them at that moment because that moment is everlasting for them.”
It’s an office that could be anywhere, except for the clinical examination bed in the corner, complete with a curtained cubicle. The A4 sign blu-tacked to the door reads: “Room booked for breaking bad news all day.”
Six medical students sit listening. “They’re real. They cry, they shout,” the facilitator, a doctor, tells the circle in front of her. Nerves crackle in the air, a few people let out self-conscious laughs. The facilitator is referring to the two actors who have come to rehearse scenarios with the students, who are one year from being qualified doctors.
Understandably, they have a lot of concerns: about getting emotional, whether or not they should touch patients, saying the wrong thing, not saying the right thing, not saying anything at all.
How does a doctor train to break bad news? By acting the part.
The scenarios are given out. The students’ eyes hurriedly scan down their sheets of paper. Cringes. Sharp intakes of breath. One scenario is based around telling a parent that their son has suspected schizophrenia. Another, that a person’s relative has unexpectedly died in hospital. One peer over his neighbor’s shoulder. “You got the short straw,” he says, shaking his head.
When the time comes, his neighbor heads for the door. “You might want to take in some tissues for this one,” the facilitator tells him. “Yeah, for me,” the young man replies.
The rest of the group watch on a live video link, seated in plastic chairs in a half-moon in front of the screen. They touch their faces self-consciously, arms crossed protectively across their bodies. The speaker hisses.
In the room sit a couple. The woman fiddles with her handbag, refusing to accept the news. The man stares silently at his hands, fists clenched around his mobile phone. “Is that true, or just something you say?” he says aggressively to the young doctor. He’s just been told that his baby, born at just 26 weeks, has severe brain damage and is unlikely to survive.
The students’ eyes dart to each other across the room. A shake of the head, a smile, a wince, sensing their colleague’s pain – the pain they are all going to feel for themselves sooner or later.
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Original article published at https://mosaicscience.com
