Conveying Bad News
by Robert S. Stall MD
A basic philosophy of my medical practice is to
keep patients informed each step of the way. I openly discuss my thoughts
after a physical assessment, what I am looking for when I recommend tests, and what I
found out after the tests came back. I strongly believe honesty is the best
policy. This is especially true when conveying bad news.
Patients who have a serious problem know that they do.
A doctor who does not acknowledge this will likely have a patient that feels let down, deceived, lied
to, and abandoned.
My usual office setup is to sit at my desk with the patient
in a chair next to the desk facing me, as shown below. From this position
I can comfortably talk with my patients, conduct much of a physical exam, and
make phone calls. More importantly, I can also easily hold a hand, touch
an arm or face, and offer a tissue.
My initial discussion about bad news is straightforward
but not blunt. For example, if cancer is likely, I usually use words such
as "tumor"
(for solid cancers) or "blood problem" (for hematological malignancies) and schedule
a follow up appointment in the near future to go over clarifying information or
additional test results. I tell
them I will contact them if something needs to be done before the scheduled
follow up appointment. Similarly, for patients with likely Alzheimer's
disease (as much a death sentence for some as cancer), I might describe
"cognitive impairment" or "dementia" and defer specifics until the next
appointment when more information is available.
I always follow bad news with suggestions on what to do next. I offer the pros
and cons of each to the best of my knowledge or arrange a specialty
consultation (often calling the specialist's office from my desk while they're
there). In addition, I emphasize that I am there for them regardless of
what choice of treatment they make, if they have any questions, or need someone
to talk to. I encourage them to page me if they want to talk to me right
away.
Breaking bad news is not easy, but to me it is clearly both
my duty and responsibility. I usually don't cry, but I hope my patients
sense that I'm not just an impersonal bearer of information but an empathetic
professional and sympathetic friend. I may even make a joke, not to convey
that everything's alright, that I
am laughing at their situation, or that the situation is not serious, but to relieve the tension
of the situation (both for their sake and mine).
Conveying bad news becomes a natural part of offering my
patients clear, honest information. I have not regretted being
straightforward, and I have not found a patient that reacted in a way that I
wish I had not told them. In fact, I am amazed at the strength people have
when spoken to honestly. As I already mentioned, patients generally know
something is terribly wrong and are usually relieved when they know what
it is.
When my patient finally leaves the office, I usually offer a
firm but sensitive handshake, a hug, or an arm around the shoulder. We'll
get together again soon, at which time we'll continue to tackle the issues at
hand together.
Copyright 2003 Robert S. Stall MD / Stall Geriatrics
Copies or reprint permission may be requested in writing from:
Robert S. Stall MD
Stall Geriatrics
14 Heritage Road West
Williamsville, NY 14221
