Through the Patient's Eyes: Delivering Life-Changing News
Through our many years of training in medical school and residency, we learn an incredible amount about physiology, pathophysiology, diagnosis, and interpreting test results. As best I can remember, no one ever taught me how to deliver serious news. It is easy telling a hopeful couple that their attempts at pregnancy have been successful, or that the feared broken bone is just a bruise, but it is not so easy to tell someone very bad news. Telling a loved one that their family member died is never easy, and hopefully it will never get easy. If it does, you might want to consider a break from medicine in order to rediscover your humanity. I have learned a few things in doing this over the last decade. First, ask the family to describe the events that led up to the patient's arrival at the ED. Second, reassure them that they did everything possible and nothing was their fault. Finally, use simple and clear words so there is no misinterpretation. Say "dead" or "died," not "expired" or "passed." Once the news is given, hardly anything else you say will be heard or understood for some time. That is why it is essential to have a case manager or someone with you to take over, so that you can step away. Always offer to return to answer more questions when they arise, no matter how busy the department might be. No matter how busy or stressed you are, this family has suffered a tremendous loss and their lives have changed forever. There is no more important time for a physician to be available.

Telling a patient they have cancer or another life-threatening disease also takes skill and tact. In this situation, the patient and family will most likely be numb once words like "cancer," "tumor," or "life-threatening" are used, so it is crucial to present as much information as possible prior to using such words. Give the patient and his family reasonable hope. Point out that the diagnosis is uncertain and further tests are required to verify your impression, and it is possible that some other process is mimicking the dreadful, worst-case diagnosis. Many times the diagnosis we make in the ED is not the correct one. I remember vividly, even hauntingly, telling a woman that she probably had lung cancer based on the radiologist's read of a spiculated nodule on a chest CT performed to rule out PE. It later turned out to be valley fever, or coccidiomycosis. I learned the value of humility and the danger of premature certainty when a diagnosis carries such incredible weight, and a biopsy or other definitive test result has not yet been obtained.

Give hope that if the diagnosis is cancer, or something equally fearful, there have been and continue to be promising advances in medicine and technology, and this diagnosis might not be as bad as it would have been 20, 10, or even five years ago. Many patients are now cured of their cancers. Giving realistic hope is crucial, but being honest and open with the patient is at least as important. Sitting at the bedside, touching the patient, and giving him time to process the information are all critical parts of delivering bad news. This is no time to seem rushed and eager to leave the room.

While I personally do not teach courses on delivering bad news, and haven't even taken a formal course on the subject, in May of this year I was diagnosed with lymphoma. In the last several weeks I have gone through almost every emotion possible, and am coming to grips with the diagnosis. I hope to use what I am going through to become a better practitioner and healer. I promise to share any pearls I discover, so that all of us can take better care of our patients. In my next article I will talk about the anxiety associated with waiting for test results, and how we can do a better job of managing that.