Breaking Bad News

"Hi Mr/Mrs So-and-so, I'm sorry to be the bearer of bad news, but the results from your operation/tests weren't very good. I'm afraid you have..."

StG organises a 2-session "Breaking Bad News" small group teaching for us, during our geriatrics rotation. I guess they thought it was suitable, death being linked to old age and all.

But the scenarios we got ranged from old-age conditions such as Alzheimer's, to chronic diseases like multiple sclerosis, to cancers, sudden deaths and prematurities. And what scenarios! The actors they got in were so professional and so into their roles that it was hard to distinguish where their real selves started - this really helped all of us get into the part of the bearers of bad news. The parts they played were hard too - 3-dimensional characters who have totally different backgrounds, perspectives about disease, mannerisms, and reactions to bad news! I thought going somewhere in the middle of the pack would do me good, show me what the situation in the interview room would be like and prepare me for my scenario, but the sad truth was I was even more nervy, and was caught unawares when my "patient"'s wife was all brisk and matter-of-fact about the whole thing and asked to keep her husband's prognosis from him. So I didn't handle that at all well, and didn't pick up on a lot of cues as I could have done.

So that's one thing - the recognising that each person has different reactions to bad news and different agendas to meet, and will give out different cues to that effect. We as doctors should be able to pick up on those cues and use them effectively to meet both the patient's and our agendas. Easy to say, but very hard to do.

Another thing that came up was our (my small group) uncertainty about what we could do. In my case, I felt the wife had valid concerns to keep her occasionally suicidal husband's prognosis from him, and though I was uneasy about it, I finally gave in to her, with the proviso that if my consultant (I was "SHO") had issues with that we'd come talk to her. What I should have done was reassure her, but leave that decision in the open, as that ultimate decision on whether to know the prognosis or not would lie in the patient's hands (unless he's that seriously cognitively impaired). Other instances where our lack of knowledge prevented us from being more fluent and receptive to the patients' needs were when a patient requested to be under another doctor, when the patient requested for a second opinion, and when the patient was indirectly asking for help with financial problems he would face with the disease. It was good to find out that most of the time, our instincts were telling us the right thing to do, and at other times, we weren't far off the mark. I think we learnt a lot about the ethical side of being a doctor today - what we can and cannot do (or should/shouldn't), which is important in our road to becoming confident competent doctors.

We, across the board, also had an inability to discuss the disease process and prognosis with the patients. For most of us, we knew the disease, but having to translate it in layman terms while keeping in mind the process of breaking bad news, was a bit tricky. There were also all those treatment modalities and prognosis indicators that we didn't really know much about. So that's more reading for us!

After this primer, I know I won't be ready when I do have to break bad news for the first time, but I would be slightly more prepared for it, as well as more prepared for being a doctor. We were told that with time, it will only become more bearable, but the nervousness will probably not go away, which may be good to keep us on our toes, not assuming things about each person we see. I must remember to embrace the nerves then.