Specialty registrar 4 in general surgery
To be a doctor is a privilege, undoubtedly, but it comes with responsibilities that can be, to say the least, onerous.
Have you ever talked to a friend out of the profession and, upon discussing the breaking of bad news, they've shaken their head, stating, 'I could never do that' or, 'rather you than me'?
I will not patronise you to tell you how hard this element of the job can be. To varying degrees you will already know. But I will say this is a chance to make a difference, to really be a doctor. For even in the giving of the worst possible news, it is the manner of doing so that can make such a difference. It is a defining point in the remainder of that person's life.
While it is true that their personality, family support and other elements will affect how they deal with the news, it is also true that you can affect in what direction they choose to set off.
We need to talk
The imparting of bad news is a key role in a doctor's job.
It is a communication skill that, like all others must be learnt and honed. Medical schools have focused intently on communication in recent years and post-graduate college exams will involve a communication element. This is evidence of the recognition, albeit perhaps delayed, that such skills are central to our work.
Though it may be awkward, the only way to learn is to watch those who are more experienced. Like any other skill in our profession, you must observe and note that which you consider good and that you would hope to imitate.
You have to be in the room when bad news is broken, as unobtrusively as possible, and only if the family or patient have no hint of an objection, but you must be there.
No one should ever be alone when ill tidings are in the air. This includes you. Patients should have the opportunity to have someone with them and so should you.
In general practice this may not always be easy but in hospital, a nurse or other colleague should always be there. They may help if you falter and, if you have to leave for elsewhere, they can stay awhile. This allows a feeling of gradually withdrawing rather than a wholesale 'Right, that's the way it is, we're all off then.'
If an interpreter is required, make it your responsibility to ensure they will be there, and make sure you discuss with them the salient points that will be covered before seeing the patient. Like you, the interpreter must be prepared; must think about how they will phrase things, what words they will use. Bear in mind that they may have significantly less training and support in breaking bad news.
You may feel the news is coming from you but it is the interpreter's words they will hear and it is to them that they will turn and direct questions. Do not forget how the situation may affect the interpreter.
Did you look after my dad?
There are several sources of advice on structuring the meeting. The Oxford Handbook of Clinical Medicine (the infamous 'Cheese 'n' Onion') gives advice on breaking bad news and included here are a couple of additional references that can be accessed online. These may be useful to skim over at work before such an encounter. The key elements are constant.
Introduce yourself and do not be tempted to obfuscation if asked direct questions.
If you have never met the patient before and you are asked 'Are you one of the doctors who looked after my dad?, explain that you are not but that you are the doctor working this evening and you did not want the family to be kept waiting.
Throughout the dialogue always use clear and direct language. Euphemisms are best avoided.
The embarrassment and hurt that can be caused when elements of the conversation are misconstrued can be more damaging than the entirely natural grief and distress that will be caused when the plain and unavoidable facts are made clear.
Have a plan for further meetings, referrals or palliative care treatment that you can discuss. This gives a more positive slant to the close of the meeting. Always document all such encounters and the salient points in the medical records.
We did everything we could
Breaking the news of a death follows a very similar pattern. An establishment of their knowledge of the seriousness of the illness or trauma if you do not already know the family is essential.
When you state that the person has died, do not rush to say any more than 'I'm very sorry.' Even if the news was expected there must be some time to allow it to sink in and nothing you say in those first few moments will be taken in. Do not be tempted to go into great detail unless the family request it and question you.
A further meeting later that day or the next may be the time to discuss matters in depth. I have seen families in bleary bewilderment while someone tries to describe in detail why the emergency surgery was unsuccessful. Anatomical terms, operative equipment, procedural names - the whole works. This is rarely appropriate.
It hurts me too
News of a terminal illness affects the patient, their family and friends, and you. Do not forget you.
You cannot tell someone they are going to die, regardless of whether you've known them a year or a day, without feeling its impact.
You may relate it to a friend or family member, to a case you've seen before, you may play out entirely imaginary and upsetting stories of how it will affect their family. Even if you attempt to not think about it, then, in doing so, it is affecting you and, more importantly, you are not dealing with it.
Remember the advice you give your patients and take heed of it yourself. Take advantage of the friends and colleagues you have.
Patient confidentiality must be maintained but you can still talk about a difficult day or having to tell someone terrible news.
Key part of being a doctor
Do not feel that you must shoulder the burden alone. The entirely natural reaction will be to be upset and disheartened.
Take a few minutes before carrying on with the rest of your work and be aware it may continue to preoccupy you throughout the day.
It is tempting to avoid these unfortunate situations and to let someone else break the news. I would encourage you not to do this. This is a key part of being a doctor and goes hand-in-hand with the accompanying privileges of being so intimately involved in caring for people.
Developing these skills through reflective practice will help improve your confidence in such emotionally charged settings and further your professional development.