dent in oncology, says the incident nearly made her give up medicine altogether. Another patient discovered a lump in her breast. Her family doc- tor referred her ...
Deliver bad news tactfully EVELYNE MICHAELS
The intern was young and inexperienced. A patient had just died on the ward and she had been requested to inform the family. Reluctantly, she made the phone call, bungled it, and the horrified family complained. Today that intern, a resident in oncology, says the incident nearly made her give up medicine altogether. Another patient discovered a lump in her breast. Her family doctor referred her to a surgeon who told her with icy formality that if indeed it was a malignancy she would do well to have a radical mastectomy and not risk the spread of the cancer. The woman left the office numb, confused, terrified. In both these cases a doctor delivered serious news and delivered it
says Dr. Ernest Rosenbaum, an American oncologist. Not only will a properly prepared and informed patient be more receptive to treatment, he says, but also "the attitudes he acquires in these initial interviews may well affect the quali. for the duration ty of [his] life of the illness". Dr. John Premi, who teaches the course "Communicating Bad News to Patients" at McMaster University in Hamilton, Ont., says studies demonstrate that better informed patients tend to do better with their illness; they cope more easily; are more functional and compliant, less anxious, and they often need less analgesic for pain relief. When giving a patient bad news about a diagnosis or prognosis, or
When giving a patient or family member bad news about a diagnosis or prognosis, it's important to have a plan.
badly. In the past, physicians, especially younger ones, have had to fend for themselves in this delicate area of medical practice. Those with inborn sensitivity and social skills have handled the situation well; others, uncomfortable in their role as bearers of bad news, have been less successful, resulting in unnecessary emotional trauma for both patient and physician. The importance of handling these doctor-patient exchanges competently should not be underestimated, Evelyne Michaels, a CMAJ regular contributor, lives in Toronto. For prescribing information see page 1324
when telling a family member about a death or serious deterioration, it's important for the doctor to have a plan, says Dr. Peter MacDonald, who also teaches the "bad news" course to family medicine residents at McMaster. He says the doctor must think about what to tell the person before doing so, taking into account the person's emotional state and how much the person wants to know. "How you as a doctor inform someone about a death, for example, depends on how much you know about the family", he says. If the doctor is a stranger to them, it's best
to say the patient has taken a turn for the worse and ask them to come to the hospital where they can be told in person and offered better emotional support. If, however, the physician knows the family and knows it is somewhat prepared, the news can be given by telephone. When it comes to a negative diagnosis or prognosis, says Dr. MacDonald, it's important to give the patient control of both the quality of the information and the timing of its delivery. "For example, one patient in whom you've detected a possible serious illness, say a rectal mass, will want to know immediately just what you suspect and the possible outcomes. Another patient won't want to know right away and might prefer waiting for further test results." Many doctors say they have trouble deciding when to use the word "cancer" in their conversations with patients. Dr. MacDonald believes the physician's choice of language is an important part of sensitive, effective communication. He says that a doctor who suspects cancer can first call it an "abnormality" and then give the patient the opportunity to ask for more detail. "Patients who don't want to know will ignore the cues. If patients have the right to know, then they have the right not to know as well", Dr. MacDonald says. Dr. Richard Hasselback, an oncologist at Toronto's Princess Margaret Hospital, agrees that the doctor should take cues from the patient in giving a bad diagnosis or prognosis. He says he tries to maintain a conversational tone in such talks and avoids lecturing to the patient. "The doctor must learn flexibility, must proceed slowly and gently", he says. Dr. Hasselback says he prefers to discuss a serious illness with the
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patient's closest family members present. This eliminates the need for repetition, avoids the possibility of mistakes and gives the patient much needed reassurance and support. "If the patient is someone who can handle only so much and I want to be a bit more direct about a bad outlook, I will often talk to the family further outside the room", he adds. In many cases the lines of communication between patient and doctor may become tangled by misinformation and well meaning deception. A patient may not know the extent of his illness because another doctor has lied to him. Another patient's family may request the doctor to withhold or soften a harsh diagnosis "for the patient's sake". Or the patient, stunned by the bad news, may simply "block out" the undesirable information. Both Dr. MacDonald and Dr. Hasselback believe that the doctor's primary commitment is to the patient. If a family member asks that a patient not be informed of a malignancy and the physician complies, says Dr. MacDonald, then he is not doing his job. Dr. Hasselback says that pleas for deception are less common today than 20 years ago when cancer was equated with certain death. But when asked, he tells relatives he will be evasive only if he feels the patient needs to be shielded from the news. He says that in some cases he has inherited patients from colleagues who have gone along with the family's wish to deceive the patient, and he has had to comply. "But sooner or later that person finds out the truth", he warns, "and any trust you've established in that doctorpatient relationship is destroyed." Dr. Rosenbaum says that in either case - where the patient's family wants to protect a loved one by 1308
withholding information, or where the patient himself asks that the truth be kept from a spouse or child - the physician should "try to explain the therapeutic advantages of treating a family as a unit". When physicians do withhold bad news from a patient, or else deliver it with insufficient care and sensitivity, this may be due to their own emotional discomfort. In his book, "When Cancer Strikes", Dr. John MacDonald, a Toronto surgeon who died of cancer in 1979, wrote: "I believe that no single group of people fear cancer more than doctors. They see it everywhere and they don't like what they see." Dr. Hasselback says it's a challenge for him and many of his colleagues who deal frequently with seriously ill patients to maintain their own sensitivity and emotional equilibrium. There's also the problem of trying to maintain contact with patients once the physician has done all he can for them medically. "When these patients do leave my care and go home, I don't want them to feel abandoned", he says. "Some family doctors take over, but others don't. I count on them to do so for these people." If a physician is especially uncomfortable dealing with a patient and his family, Dr. Peter MacDonald of McMaster believes other health care professionals - social workers, nurses, psychologists, counsellors can help handle the family's questions and concerns. Dr. Hasselback makes a point of teaching proper communication skills to residents and interns at his own hospital and tries to have them sit in on doctor-patient conferences whenever feasible. He believes that such efforts by more experienced doctors, plus "bad news" courses, will go a long way in teaching how art overlaps science..
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