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I’ve been a practicing physician for 20 years now. In this series, I’m sharing some of the best practices and helpful phrases I’ve learned for talking about bad news and end-of-life issues with patients.
In Parts 1 and 2, I tackled some strategies for some of our most difficult medical discussions. Time to back up for some basics. Twenty years ago. I was an intern, a first-year physician, with only a few months of experience. But I still knew a few things about breaking bad news.
Sit
My patient had suffered a series of heart attacks, and despite the best available medical care, his heart could no longer pump enough blood to his body. We call this heart failure—we throw this term around like it’s nothing because it’s a common problem for us, but what a terrifying phrase!—and his was bad enough that he had low blood pressure and had gone into kidney failure. Without dialysis, he would die, but we worried he could also die suddenly from dialysis, because it would further lower his blood pressure, triggering a fatal arrhythmia. The supervising heart and kidney specialists began telling him this standing up and uncomfortably far from his bed like they might need to run for the door.
I went to the nurses' station, got some chairs, and pushed them into the doctors from behind so they had to sit down. Because when you’re telling someone they could die within a day or two, you want to look like you’re willing to devote some time to the issue. It’s simple: pick a time convenient for the patient, make sure the right family and friends can attend, anticipate the likely questions, and when possible, hand your pager off so you won’t be interrupted. Make sure everyone is comfortable, and bring tissues. People notice.
Be honest, be clear
A middle-aged man came to the clinic after an ER visit for back pain. Labs had shown anemia and elevated calcium. A scan had shown innumerable holes in his skeleton, so-called “lytic lesions” where cancer had eaten away the bone. This combination of findings almost always means multiple myeloma, a kind of cancer of white blood cells. I began by checking on his understanding. “They just said I really needed to see a doctor.”
I couldn’t believe it. No one had told him.
You have to tell the truth, and usually as soon as possible. But there’s a way to be honest without being brutal. Breaking bad news is a process, not a single event. “There’s a number of things that can do this. We don’t know yet, but I’m worried that this might be cancer of your white blood cells.” It wasn’t a fun thing to say, but it was the right thing to do, and frankly, I’d find it harder to say something evasive.
Be honest, be clear, but be gentle
Then I help patients prepare for the confirmation, which usually comes in the form of a biopsy result, but sometimes is a scan or other test confirming tumor growth or spread. “When this happens, I say, ‘Hope for the best, prepare for the worst.’ Let’s just assume it’s cancer for now. If it is, when the result comes, we’ll be ready for it. If it’s not—maybe this is some kind of unusual infection or inflammation—then we’ll celebrate the news.”
When it comes, the magic words are, “We did get your results back. They weren’t what we hoped.”
It’s a process, not an event
Patients can receive other bad news stepwise, as well, softened with a little positivity. “We’ve confirmed it spread to your liver, but your liver is working normally.” Sometimes, the full impact of that result (the cancer is now incurable) can wait. Occasionally, it’s helpful to soften even that news: “We know the cancer will always be with you, but that’s true for most diseases I manage. Diabetes, emphysema, hypertension—we manage those things, they rarely go away.” Then you lay out the treatment options, which are sometimes excellent. You point out that research is ongoing, and new therapies might become available.
I mention the example of metastatic melanoma, which until recently was a treatment-resistant, vicious disease. Jimmy Carter learned he had it in his liver and brain in 2015, and without new therapies, he would have soon died. He received new immune-based treatment, however, and had an excellent response. As of this writing, he’s 96 years old and likely to die with a history of melanoma. Not from it.
You can also lay the groundwork for the future. “Right now it makes sense to remain full code; you’re strong and healthy. If and when that changes and ICU care isn’t a good option anymore, I promise to tell you the truth.” You can say the same thing about the cessation of chemotherapy and the transition to hospice.
These magic words prepare the patient for what may be inevitable transitions. And they convey, from the beginning, a promise to tell the truth. I’ve always found that’s appreciated.
Thanks for reading. It’s been quite a journey and privilege taking care of amazing people at some of the critical and vulnerable moments of their lives. I hope these pieces have been helpful to those facing cancer and other serious diagnoses. In the next entries in this series, I’ll share my tips for answering a really tough question: “How long have I got?”
