TONY: Bad News

Hello Loyal Readers,

I wanted to take a quick minute to post a reflection piece that I wrote recently about breaking bad news to patients.  As a student on any rotation, you will have to be the one to (or be part of a team that) must deliver bad news, and believe me when I tell you that it is one of the most difficult skills to master.  Some doctors go their entire careers without fully grasping the importance of the subtleties of this delicate patient interaction.  Fortunately for me, I was recently working with a young doctor who, in my opinion, is off to a great start…

Mr. S is a 60 year old African American male, a man who lives with his wife, and is close with his many children.  Mr. S was not my patient, so I did not follow his hospital stay at Emory very closely, but I did round with my resident on him the day that lab tests determined that he had metastatic pancreatic cancer.  When we arrived, Mr. S was downstairs getting an ultrasound done, but his wife and son were in the room.  I remember that they had been sleeping when we knocked—it had been a very long and emotionally draining hospital stay.  Although they had had no idea of the severity of Mr. S’s disease when they arrived a few days ago, the seed had been planted by their medical team that cancer was a very real possibility.
My resident and I knocked and entered the room, greeted the family and both took seats.   The four of us were clustered near the window, looking out on the fading spring sun.  After we made our introductions, my resident told the family what our tests had confirmed.  The family members simply nodded—they had been expecting this.  Their strength, as it appeared to me, was clearly fragile—hanging by a thread.  This made it all the more important that the remainder of this conversation was delivered in a way that respected the fact that the family’s emotional breaking point could occur at any moment.
I felt that my resident negotiated this beautifully.  His tone was always calm, and inviting of questions.  He gave a brief overview of the differences between palliative care and chemotherapy, discussed the merits and drawbacks of both in lay terms that did not condescend.  These are the things that any good doctor should do when delivering bad news.  What I believe was truly special, and what I believe I learned most about, was my residents knowledge of the times when words fail.  There were many breaks in this conversation where there would be no words.  Not because he had asked a difficult question or because anyone had broken out in tears.  It was, quite simply, because there are times in these difficult conversations when silence is more valuable, respectful, and encouraging than words.  My resident knew this, and perhaps more importantly, he did not fear it.  Sometimes we would sit with the family mid conversation for what seemed like an eternity to me, but turned out to only be about twenty seconds, and simply be present.  I felt that I could see the family members digest each piece of life-changing information piece by piece during these pauses.  They asked questions when they felt they needed to, and kept silent when they didn’t.   The entire conversation may have only taken 15 minutes, but I felt that each moment was well spent, and no word was wasted.

Stay tuned, kids.  My next post will chronicle my second (and significantly more epic) trip to Haiti!