Physicians have the unique duty of giving patients and their loved ones the worst news people can receive. It may be complicated, heavy, dark, somber, terrifying, and hopeless. It may also be a welcome, a relief, an ending, and a beginning. It is as important as anything we will ever say or do with or for our patients.
Research shows that the attitude and communication skills of the person delivering the distressing news are important in determining the course of a family’s ability to cope and recover from tragedy. I’ve carefully studied giving bad news and communication in general throughout my professional and personal development. It has been a priceless investment.
One patient I recall, to whom I found it especially difficult to give bad news, was Tony. I had to tell him he had AIDS long before there were treatments. Before he arrived for his appointment, I mumbled and paced, and mumbled and paced, hoping that the “right” words would spontaneously come to mind. My anxiety was in vain. Tony knew, in his gut and his heart, why my staff had called him to come in. We just sat in the exam room; few words were exchanged. He didn’t need to hear any bioscience. He didn’t need to know the natural course of the disease. In those defining moments, the only thing Tony needed to know was that he wasn’t alone – that he would see me at his next appointment, and the appointment after that, and the one after that. So, we just sat until Tony was done sitting – about 15 minutes. It’s called therapeutic presence (a.k.a. suit up and show up, + or – shut up.)
Another patient I remember too well was a 2-year-old boy who arrived at the ER after a catastrophic motor vehicle accident. He was holding tight to life with his tiny fists, but his grip weakened. He slipped away. In a small, windowless room that no one ever wanted to enter were at least 25 family members and friends gathered around my small patient’s mother. I knelt next to her chair, eye to eye. I told her that we did everything we could, everything medicine had to offer, but it wasn’t enough; he didn’t make it. I stayed by her side until she didn’t need me so close. I was her therapeutic presence. She didn’t ask for, nor did I offer details. They were offensively irrelevant.
Most physicians feel that delivering unwelcome news is one of the more difficult of their duties. Few have any training or opportunity to build confidence in communicating distressing news – we’re comfortable with helping and curing patients. Some physicians are reluctant to discuss a diagnosis for which there is little to offer. Other physicians feel like failures if a cure is not possible. When under pressure, some physicians blurt out promises which are just false hope. That’s insensitive, even cruel.
Any of the reasons above, which a physician might use to rationalize avoidance of delivering unwelcome news, are about relieving the physicians’ discomfort. The news, however, is not about the physician. It’s about the patients and their circles of belonging. In these times of need, self-interest does not supersede our patients’ best interests.
An article I read in preparation for writing this stated that time constraints, as well as the challenges of getting paid for these interactions, can become a burden. It had never occurred to me to make time or payment determinants of service in this context. I have found that no matter the size of my giving to my patients and their families, it is never as much as they have already given me. We all – patient, family, friends, and me, become part of each other’s stories, however briefly. Sitting with the family by my patient’s bedside as s/he leaves earthly life is a great honor. It is not possible to overstate the family’s gratitude and relief that you are close. It is easy to forget that to them, this passage is mysterious and intense, as real as life gets. Your words can quickly be forgotten, but those you serve will always remember the feeling of your caring presence.
With the population aging, physicians are expected to face more of these difficult discussions. We need to cultivate, with greater intention, our understanding of the social, psychological, and cultural contexts of our patients’ lives and the trusting relationships we build with them over time. These relationships will help determine how and to whom we deliver difficult news and provide insight into how it will be received.
Faith A. Coleman is a family physician.
