(Thanks to Doug Wilson, MD, president of the Napa County Medical Society, for the idea for this post.)
One of our hardest jobs as physicians is delivering bad news. It is emotionally draining, time-consuming, and uncomfortable. Most of us received very little training in medical school on how to deliver bad news. And it really does require some training. While many physicians are intuitive by nature, delivering bad news honestly, candidly, gently, directly, empathetically, and supportively does not come easily for most of us.
For many physicians, we tend towards one of two extremes. On the one hand, we sometimes try to shelter patients from bad news by presenting information through rose-colored glasses. “You’re going to be OK.” “We have some new treatment options that are showing a lot of promise.” “You’re doing great.” Phrases like these – when spoken to patients with incurable serious disease, who are often looking for any kind of miracle – are meant to reduce worry and allay fear, but they can be misconstrued. The short-term gain such statements provide can make the grim reality, which cannot be avoided forever, even more painful. If we falsely raise hope when there is no valid reason to expect a good outcome, we are not doing our patients any favors.
On the other hand, we also sometimes go to the other extreme of being too blunt, to the point of seeming callous. When first delivering some very bad news, it does not help to say, “There is nothing we can do.” “There is no hope for improvement.” To extinguish any sense of hope, to state without hesitation that the game is over, can make patients and their families feel abandoned, uncared for.
So how do we balance contending priorities? To be most effective, physicians need to be consummate jugglers. We need to be able to deliver bad news compassionately and caringly. We need to let our patients know that we understand their concerns, fears, and emotions. We need to let them know we will stand by them and help as they embark on their new and perilous journey.
While good communication is essential in all clinical realms, it is particularly important when talking about the delicate matter of end-of-life care. Even the term end-of-life is an ominous phrase. It can evoke the worst fears that humans experience. Patients and families, when facing the prospect of life’s impending end, often and understandably want to delay the inevitable. They may ask their physicians to “Do everything.” Their motivation in asking for “everything” is understandable. But that plea often reflects a flawed awareness of what “everything” means. Patients and families are often unclear on just how painful and ineffective some interventions can be. Their plea is a call for help, and it requires the physician to spend time communicating, realistically and compassionately, with the patient and their family about what lies ahead.
No, our job is not easy. But then, none of us asked for easy when we decided to enter this profession.
The Journal of Clinical Oncology recently published an interesting perspective piece on this topic. You can find it at this link: http://jco.ascopubs.org/content/30/27/3421.full.
Richard Fleming, MD