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Breaking Bad News

Ben_3Ben Bryner -- As a medical student, I have informed exactly one person that they have a terminal illness and are soon going to die. Of course, this wasn't a real patient, but a "standardized patient"  (or SP), someone trained to act like they have a medical complaint and then answer questions and sometimes simulate physical exam findings like a real patient would. The SP's role has been popularized by Kramer (from the series Seinfeld) who took a job as an SP. However, Kramer's SP performance was a little over the top. Plus, in real life, the session with an SP usually includes a complete history and physical as well as talking about possible diagnoses and treatments, not just med students shouting out potential diagnoses. (Also, isn’t that med student the guy from Lost?)

Any field has some kind of facility for simulation, and this is it for the history and physical exam. Generally, our SPs have been very good. Most of our experiences with SPs are in the first two years, to gain experience in clinical settings before we are sent off to the wards, or in testing situations to formally assess our history-taking and examination skills. But occasionally in the clinical years, our school sets up SP experiences to help fill in gaps that don't get addressed on rotations.

On the surgery rotation, there are plenty of patients who get bad news, but students often are not around when the surgeons inform the family (often because they lack the longitudinal relationship with the family, or they're simply busy in the OR or conference, or other reasons). So during our third-year surgery rotation, we practice giving SPs "bad news." There are some articles to read beforehand, as well as some advice on how to answer the most frequently asked (but impossible to answer) question of "How long do I have?" Maneuvering around this question is one of the hardest aspects of breaking bad news, because the goals of communication in the doctor-patient relationship -- including accuracy, encouragement and openness -- are completely at odds when answering it.

Breaking bad news is perhaps the toughest task in medicine. For that reason, if you Google “breaking bad news” you can find dozens of books and articles devoted to the subject. You may also find the words to 50 Cent’s song “Bad News,” which are actually not very helpful in this case.

But speaking of words, one of the other difficult things we are supposed to learn from this SP experience is using specific language, like the words "dying" and "death" instead of euphemisms that are likely to be misunderstood. This table is about my favorite of all the tables I've ever seen in medical journals. The rest of the article (Berry S. Just Say Die. Journal of Clinical Oncology. 2008;26:157-159) is an oncologist's discussion of how physicians can help their patients by being direct when the situation requires, and how this is compatible with a compassionate doctor-patient relationship.

Dr. Berry sums up: "One of the reasons physicians find end-of-life discussions so difficult is the belief that these exchanges, and in particular using the words 'death' and 'dying,' could distress our patients. Avoiding harm is a central tenet of our ethical conduct as physicians. However, it is possible to use the words 'death' and 'dying' in talking to seriously ill patients, as long as it is done sensitively; their use may actually avoid harm if they clarify the discussion." (And as Dr. Berry points out, calling them "end-of-life issues" is just another euphemism we use to avoid the word "death"; we don't congratulate new parents on their "beginning-of-life event.")

It's worth practicing. Even in an artificial setting, even telling myself beforehand that I needed to be direct, I had a hard time telling my standardized patient that she was going to die. I had to force it out, even though it would have been easier to hide behind phrases like "your cancer is terminal" or "the prognosis is very poor in this kind of situation" that I'd use if I were describing the case to another health-minded person.

Of course, at some point I'm going to have to take responsibility for giving a patient bad news for the first time. Since that rotation I've had a few chances to observe the process of giving bad news, and hopefully I will be able to adapt what I've seen and heard. I was glad for the experience with the SP if for no other reason than to become aware of how difficult it can be for a doctor to speak openly and plainly when discussing bad news, and how important it is to be clear.

April 20, 2008 in Ben Bryner | Permalink

Comments

As one who had Stage IV inflammatory breast cancer with mets to the brain, lung, skin, bone and 42 nodes, we must also be careful to not pronounce death as something imminent. I was told repeatedly by many physicians at five different facilities that I would pass on, had a grim or poor prognosis, could be treated but not cured, etc. Each person was quite certain I was going to die, it would be very unpleasant and it would be quick. Eleven years later I am still here doing fine and haven't had a recurrence in just over five years.

Taking away hope is something physicians must be very certain not to do while giving the facts we do know. None of us is God and certainly don't know when anyone will die. Statistics are meaningless because the patient is a statistic of one.

Just some thoughts

Posted by: Lisa | Apr 22, 2008 4:39:39 PM

From a nursing student (oh, stop....! read on anyway!): We've been told patients don't hear much, if anything, past "You've got cancer." I've heard from many cancer survivors that they wouldn't have wanted to have heard, "With your type of cancer, you've most likely got about 6 months...8 months." They always seem to say to me, "I wasn't ready back then to hear that, and I'm still not." (having "recovered" or in "remission" now). I'm about to precept into an ER here in San Diego tomorrow. HELP !

Posted by: Nancy Chardt | Apr 22, 2008 4:56:06 PM

Specific consequential dialog is also vital in non death situations.

From the family and or friend care giving perspective I have seen beating around the bush lead to longer hospital stays, additional suicide attempts and brain damage from such attempts.

Ultimatums of no longer caring for a patient or family member if they do not e.g. take their medicine, seek a med change, push away destructive influences etc., is not tough love it is often communicating the simple truth before the care giver is so burned out, that the patient is left with NO intensive support resources.

The patients well being immediate, short term and final stage is so important that we should gladly sacrifice their affection for us. And sometimes that is precisely what must be done. Patients often have a hard enough time making decisions under many distressing influences, financial, family, pain etc, they don't have a chance at all with out simple real assessment. Make eye contact, make sure they understand you.

Posted by: Stephen Casey | Apr 22, 2008 5:09:41 PM

Today New Yorks Time has an essay on this subject:

"At Bedside, Stay Stoic or Display Emotions?"

by Dr. Barron H. Lerner, who teaches medicine and public health at Columbia University Medical Center.
http://www.nytimes.com/2008/04/22/health/views/22essa.html?th&emc=th

Posted by: Stephen Casey | Apr 22, 2008 5:31:15 PM

There are many similarities in how physicians and other medical professionals handle the so-called end-of-life dialog and how we, who confront end-of-life from the "other end", handle it. One grief counselor, Harold Ivan Smith (cited at has suggested that the hard words for death are crucial indicators that the grieving are working through the process. It is my personal view that these hard words are often avoided in end-of-life dialog (assuredly to spare feelings, a sentiment which I fully understand), but in doing so not only the dying but those who mourn their "passing" (see that soft word, again? here use to avoid unnecessary repetition)...I say, those who mourn the dying and their deaths are unduly insulated from beginning this process at the very outset.

In my work of minstry for grief, I ~always~ use the hard words, but in very selective ways. I've stood beside bedsides as physicians informed patients of impending--and even imminent--deaths; many MDs struggle with this perhaps-perceived loss of professional control, but always seem to find the words, though sometimes in a bit of a clunky fashion. Often patients and families will look next to me, as though searching for someone to interpret the words they have just heard. In these cases, I ~never~ avoid the hard words, but again, am careful to soften the timbre of the words in my own tones and the framing of my own sentences. After all, it could be me or my family... (another psychological trap, to be sure).

I applaud the budding Dr. Bryner for his guts in broaching this most difficult and emotional subject.

Posted by: rpbell | Apr 22, 2008 6:14:26 PM

Oops...

The URL for the citation of Harold Ivan Smith's point didn't make it, viz. http://bobbittchapel.com/article.aspx?IXF=734

(let's see if Medscape strips the URL before posting...hmmm?)

Posted by: rpbell | Apr 22, 2008 6:19:16 PM

I feel that this is a very important Subject that should be discussed with any Family Members also. My own experience when My Wife died was a tremendous strain until I came to grips with the fact that Her sickness was definately going to kill Her. I spoke quite frankly with Her Doctor and He said She was going to be in and out of the Hospital until Her Heart would finally give out. That is exactly what happened. She had Pumonary Fibrosis with Enlargement of the Heart.

Posted by: Vernie Treadway | Apr 22, 2008 7:04:28 PM

Ben,

You have touched upon a very sensitive but crucial aspect of health care especially cancer care. As a medical oncology fellow I deal with this on a day to day basis. Breaking bad news (BBN) and then discussing prognosis without taking away hope and the will to live from the patient is very challenging. This has to be approached keeping in mind that each patient and the situation is different. The key element lies in patient physician communication and if physician's can communicate effectively then we could do a better job at BBN. A module developed at East Tennessee State University can help health care professionals develop better communication skills in the delicate subject of BBN. More work in this regard is being presently undertaken.

http://qcom.etsu.edu/communication/index.htm

Posted by: Harsha Vardhana | Apr 23, 2008 9:09:07 AM

Very nicely written.
One of the very few Medscape articles that got me hooked on.

Posted by: Atif | Apr 23, 2008 11:18:19 AM

As Med. student, I would like to sugeest that anyone giving such breaking news to a patient must have the knowledge of all medical ethics and of course the passion. Also must assess the psychological and mental status of the patient rather than breaking out.
some medical workers get insulted or bitten soon after breaking such information to patients who were not earlier prepared psychologically

Posted by: Mabula, P | Apr 24, 2008 6:06:15 AM

Thank you for bringing this important subject to the fore. At our hospital, board certified chaplains work as an integral part of the treatment team and are frequently called upon for support in situations where doctors must break bad news.

Hospitals can be confusing places for patients at the best of times. Openess, honesty & clarity are the least (and sometimes the most) we can offer our patients and their families. They may not thank us in the moment (or ever), but when news is delivered in a sensitive and unambiguos way, this may allow the patient to reconcile with events & people from their past, and to take full advantage of their last hours, days and months. The opportunity to pre-plan their own funeral is another gift that we give to patients when we confront our fears and are direct about their prognosis.

I close with an extract from an audit supported by the Royal College of Physicians (see summary at: http://www.rcplondon.ac.uk/news/news.asp?PR_id=381) that highlights "the potentially negative effects of the use of euphemisms and jargon when explaining complex healthcare issues with patients and carers."

Respectfully,

Rabbi Daniel Coleman
Chaplain, North Shore University Hospital

Posted by: Rabbi Daniel Coleman | Apr 24, 2008 11:09:47 AM

So UseFull

Posted by: Salman Vosulipour | Apr 25, 2008 7:53:53 AM

well in death matter, the dialoge is only going one way, that patient is going to die in a certain period, but the dilemma i find is that how to tell our patients that they have a disease of poor prognosis, but still not sure, would u tell him that u could have this disease, so u can make it easeir the next time u r sure of diagnosis, or tell him/her that we r not sure of anything and face the consequence later if he/she has a serious illness, or just benign condition....

Posted by: nader | Apr 25, 2008 11:50:07 AM

I think it really depends on the education status, the personality and mental maturity of the patient in general.
while breaking a bad news make sure that u are talking to the patient and if there is some one else then know the relation and responsibilty of the pt to that particular person.
if feasible deliver the news in "pieces".small bit at a time.

Posted by: jamil | Apr 29, 2008 2:24:59 AM

I am impressed... here in Brazil I had never heard about this kind of training... SP... for sure, it´s very usefull! Here, most of times you just end up "geting the way" with mistakes, time, seeing others, trying, supervisioned... but not like an encenation... loved the idea!

Posted by: Dailson | Apr 29, 2008 9:12:06 AM

Hi Ben, it was good read your story about breaking a bad news to the patient, it is a tough time to tell it. But first of all before break the bad news, off course we must reassure the prognosis and the course of the disease, collect all possible evidence including all lab data(s). Remember your role as physician, empathy, not sympathy. Tell briefly to the patient in exact moment privately, then, if necessary, to the patient's family or closest's relation. Here in my country, there is no SP, we practically did it directly toward onward patient under supervision by the in charge supervisor doctor.

Posted by: Albert | Apr 30, 2008 8:14:26 PM

here in my country, only the attending can break that kind of news... if ur a clerk, an intern, or even a resident, u jst have to kindly tell the patient to address their questions to their attending should they ask u... this is to avoid any conflicting comments...

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