Volume 199 - Issue 10
A difficult conversation
Author: Emma Foster
Med J Aust 2013; 199 (10): 704. || doi: 10.5694/mja13.10254
Published online: 18 November 2013
Published online: 18 November 2013
Breaking bad news is a necessary, never-ending challenge for doctors.
Investigation results are a false crutch for breaking bad news to patients
Several years out of medical school, I was working my first general medical registrar job as the night cover in a rural hospital. An elderly gentleman, unconscious and intubated, was brought in by ambulance to our emergency department. A computed tomography (CT) scan of his brain showed massive bilateral haemorrhages. I phoned my consultant, discussed the case, and agreed that a “not for resuscitation” order was appropriate.
An urgent family meeting was arranged.
At 2 am I entered the relatives’ room, expecting one or two people. There were 15. They were crowded in the room, some standing, some in pyjamas, all white-faced and anxious.
None of them knew that this man, so special to them, was now lying unconscious in the next room, breathing through a tube, irreversibly damaged. I introduced myself, and thanked them for coming. I looked at the expectant faces. They already knew of the unconscious collapse. What “warning shot” could I give, to help steel them for the bad news? I thought about the only new information I had: the cerebral CT results. These were so clearly bad; surely they’d allude to the dismal outlook?
“The brain scan was very abnormal. There were large blood clots on both sides of the brain. So big, they had compressed the ventricles.”
I paused, the warning shot duly delivered.
Fifteen bewildered faces looked back at me.
Only one person was shocked. It was me.
What was I doing? I know the importance of not speaking jargon. But here I was, hoping some test results would do the hard yards, would explain the tragic event, would hint at the sad prognosis. A man’s life was at an end, an eventful life, a life he had shared with all the people in this room. And I had tried to describe an axial slice of his brain to people with no medical background.
Of course, mishandling the breaking of bad news does not happen infrequently. Medical schools supply us with a framework; verbal and non-verbal tools. But it is hard to recreate those leisurely afternoons in sun-filled tute rooms. Everyone is your age, speaks English, knows the drill, and — this is most important — is not actually about to be bereaved. Nothing prepares you for the real thing. I had asked a mentor once if it ever got easier. “No. But you get better at it.”
Breaking bad news is a necessary, never-ending challenge for doctors. Each situation is unique, each tear-stained face exacts its emotional toll, each condolence is accompanied by a bitter feeling of inadequacy; inability to save every life, inability to ease loved ones’ pain. I wonder how many of my colleagues use investigation results as a means of deflecting or avoiding these issues.
Maybe it is easier to “clinicalise” the truth, talk about reports and numbers, rather than about the imminent death of the person in front of us. But conversations like this are not fair to people who deserve an honest and sensitive discussion. The medical profession deals in difficult decisions and difficult conversations in the service of the patients and their families.
That night in the relatives’ room was hard. I started again, and I watched as my carefully selected, layman-friendly words tore the world apart for 15 people. It was the first time I had to say the real words — the words I had tried to imply by relating a test result, the words that the family needed to hear. “I’m very sorry, but he is dying . . . he will die.”
Months afterwards, I asked myself: if I had not said it, would it have been less real? I thought back . . . I watched as my words took hold. I explained how their loved one was not responsive, had a tube in his throat, and that this would be distressing to see. All were determined to see him one last time. I escorted the family into the resuscitation area, watched them take it in turns to hold his hand. I watched, as the last goodbye was said, as the patient was extubated, and as he slipped away. I watched, as 15 tear-stained faces left. And I had my answer: it was real for the patient, it was real for his family and friends, and it deserved the real conversation that we eventually had.
Competing interests
No relevant disclosures.
Provenance: Not commissioned; not externally peer reviewed.