How can doctors do this better?

[Mushypeas101]

I often give people bad news. It’s part of my job. I’m not an oncologist - I’m not the doctor that gets to give people a bit of hope.

I often see people on here say things like “the doctor was horrible, the doctor was blunt”.

I try to tell people quite quickly in a clinic appt (but that, I mean I don’t spend ages explaining possibilities, what’s happened up until now) so that the period of time of anxiety is reduced somewhat. I believe I do say it in a kind way but equally I feel I have to say exactly what I mean to avoid false hope or patients getting the wrong end of the stick. I always try to balance the bad with something positive.

Was I given training? Er, a bit. But not really. You’re suddenly a senior doctor and people look to you.

I just wondered if anyone has had a doctor who broke bad news “well”, how was it done?

I don’t think you can give bad news clearly and gently in a way that people won’t feel it was horrible because it is horrible and many people can’t separate the message from the messenger

I’m sorry that you have to do this as part of your job. It must be extremely difficult. It’s really good that you are trying to think about how to minimise the pain for those you’re telling. I think you’re right to tell people promptly. Potentially, leading in with, I’m very sorry. I appreciate that might not mean much, but it gives a sort of warning of what’s to come. I think being as clear and direct as you can is helpful too, as it is human instinct to try to soften the blow, which can lead people to obsfucate and also human instinct to look for the positive and, effectively, not hear the negative thing being said amongst any obsfucation. Hopefully, others with positive experiences will come along. All I can say, as you probably know, is that people remember when someone does it badly. My husband still talks about when the doctor broke it to them that his father’s cancer was terminal (20 plus years ago). They asked if the treatment was working and the doctor said, well, do you feel better? My husband remembers it being with a smirk. I suspect from the doctor’s point of view he was trying to lead my father in law to draw his own conclusions - possibly thinking it was gentler or avoiding the more difficult words - and any smirk was nerves, as I dont imagine anyone enjoys this part of the job, but that was not how it was received by the people in the room. I am not sure there is a good way to do it though so much as less bad ways. I hope others will come on with experiences of relatively positive ways that the news has been broken that might be helpful to you. If you’re thinking about how it feels to receive the news, I think you’re probably halfway there.

I think it's not about the doctor, it's about the patients. Personally I would always prefer unvarnished and blunt (with a side order of black humour), but I expect that some others would be shocked by what I consider just straightforward provision of facts. Given how much people differ, I think a doctor's only task is to give accurate and clear information. It is absolutely not their job to be sympathetic (and many of us would hate that). In reality, just accept that its not possble to be all things to all men (and women).

This is true. Interesting about your sympathy point- when it’s a particularly awful consultation and someone is very upset, I often say “I’m so sorry”. Maybe people don’t want that but actually I think they’re not listening by this point and I’m saying that to fill the void of silence/tears.

(I do have nice parts to my job too! Ha)

@Mushypeas101 In my opinion -
Make sure you are somewhere quiet and private.
Start with, "Sometimes, Doctors have to have difficult conversations with patients." (pause)
Be direct and clear, give the bad news without delay (pause).
Then focus on the next steps and support.
Followed by, "Have you any questions?"
Give them time.

The Hospice close to me had an Education Centre which ran one day courses training Doctors exactly how to break bad news.

I was very friendly with the Education Centre manager who was stunned that these skills, so essential to the way individuals deal with a shocking prognosis, hardly feature in a Doctors training.

My DH died an awful death following an accident and despite the terrible things I witnessed and experienced while he lay dying in a Coma for 10 weeks, it is still the way I was told he would ‘either be a vegetable or die’ that shocked me the most. I still have flashbacks about the way that prognosis was delivered 20 years later.

Moreover, it was a senior Consultant who delivered that information and then swept out of the room leaving me totally alone to digest what had been said. I actually felt sorry for the lovely Nurse who found me 10 minutes later and had to mop up my puddle of tears.

I don’t blame Doctors that have not had the training required in the skills of imparting a shocking prognosis, but firmly believe that training in this area is essential !!

Perhaps it depends on where and when you trained. One of my DC, 10 years ago, was taught and tested extensively on “giving bad news”. ( I know because they used me to practice the speech! )

The way people react to bad news is variable. I had to go and tell a patient they had pancreatic cancer and were dying and the wife complained that she wasn't happy id phoned in advance to tell them I was coming. I was really shocked. I always phoned patients to say I was on my way but to her it was extending the agony as she knew something was wrong. I've given bad news on many occasions but this was the first I'd experienced this reaction. I've lost a husband aged 50 to a brain tumour and a mum over 10 weeks with a neurological cancer and a close colleague to pancreatic cancer (6 weeks) so it's not like I'm immune to feelings but I was actually really upset by the reaction. But I took a deep breath and moved on as the poor wife was heartbroken and that was the main thing to concentrate on.

Giving time after breaking the news for it to sink in. Giving information, phone numbers etc

Almost exactly a year ago our GP told me that my mum was approaching end of life. (She was living with us) I knew in my heart that this is what was happening but I needed his confirmation.
He was absolutely amazing, couldn't have been kinder in delivering the news. He was very factual about what was happening & what was to come eg District nurses attending every day if needed. Palliative medication delivered to the house etc. No false hopes but just facts in a kind way.
My mum passed away a couple of weeks later at a weekend but he phoned me first thing on the Monday to check on me & go through the Death Certificate procedure etc
This was old fashioned "GP ing" in action and I will be forever grateful.

I have seen good and bad.

When it was my mum’s turn for the worst news, the consultant was very kind; confirmed the diagnosis, the metastases, and the limit to treatment. He was direct but his tone was clearly empathetic.

He answered my questions as it was clear mum was overwhelmed.

In contrast, the awful registrar who told my dad his cancer was terminal, apparently stood at the end of his bed, in the ward, and told him he was dying.

I think tone is very important. It must be so hard, but I think trying not to sound like it’s a matter of routine to you , does help.

You should have proper training in how to do this. It's not fair on anyone that you don't.

When people say they have been told bluntly I don't think they usually mean that the actual words were too direct. I think they mean something like "I was just told this terrible news and then left to get on with my life".

Here are some general pointers, hopefully you already do a lot of these (maybe more than you realise):
-the tone of the meeting is as important as the words you say
-news should always be delivered in person and it's good practice to tell the person that, if possible, they should bring someone with them
-you should be in a private space where you won't be disturbed, and have time. Some people will want to get out of there as soon as possible, others will have a hundred questions or just need to sit. When you say "I try to tell people quite quickly in a clinic appt" this is a bit of a red flag to me.
-don't have a long lead in to the bad news. "I'm sorry, this isn't good news" then into it, directly and clearly but using a gentle tone.
-for most people, it helps to explain how you have reached that conclusion. What the tests/scans or whatever mean and why they mean it's bad.
-i don't think you need to end with something positive, people can see through that if the news is bad. Just another "I'm sorry", a hug if it seems appropriate.
-What people want is to know what is going to happen. What is the plan, is there treatment? What is the likely timeframe? Can you reassure people they will continue to be supported and without pain?
-consider where people can get further support. If you are talking about death planning, there are organisations that can help. It might not be appropriate to share those there and then, so you could offer a follow up email ("let me know if you would like me to send you these when you have been able to think about it/talk to x, you can contact me on x"). If it is palliative care, you can offer information about how this will be accessed.
-people usually struggle to take in bad news and think of all their questions then and there, it's good practice to have a number or person to contact with questions once they've had a chance to think.
-in terms of ending the appointment, you should ask if they have any questions then give them space in the room - make it clear they can leave if they want to, or they can remain in the room on their own for a period of time to digest the news.

The bad: Dr could have been telling us our football team just lost. Chewing gum, appearing uninterested as he delivered the devastating news.

The good: private room with a nurse also. Listened, explained and was direct. Showed empathy.

I think showing you care is a good start. It can’t be easy.

The consultant who had to tell my husband he had cancer again and it was terminal was brilliant. Really couldn’t fault his empathy and care, my husband just heard “you’re dying” and that word wasn’t used. Afterwards he couldn’t remember anything beyond “terminal”.
It often isn’t anything else the doctor or their team could do differently.

I prefer the facts and statistics and no wooly platitudes. DH is the opposite, so when dealing with emergency surgery for small DC, there was no right way for the staff to tell us bad news.
Just never do what DC initial consultant did, sweep in with 15 students, snap at me to turn off the telly and seem really cross when delivering a life altering diagnosis. She redeemed herself over the years, but I'll always remember how hard she made an already hard moment.

My husband was told he was dying when he was alone in hospital - limited visiting allowed as it was towards the end of the covid restrictions. I was so upset that I wasn't there - I asked to speak to the (different) consultant with him, and that doctor was so kind and assured us he wouldn't be left in pain.
I would say make sure the patient has support from their loved ones if at all possible.

I actually disagree with this, I think most people want the news direct and clear, few people want false hope or someone to cry with them. The problems come, as you can see from the comments, when the news is delivered in inappropriate settings (end of bed, noisy ward) by people who don't seem to care and who themselves want out of there as soon as possible.

When my partner died I had a phone call to tell me to get to the hospital asap (which was fine, and I knew it was going to be bad). But I then had another call in the taxi to tell me he had died. That was totally inappropriate and still haunts me now. The issue was nothing to do with the words used. It was pure thoughtlessness.

When I was a bowel cancer nurse we all (including the consultants) had to go in a “breaking bad news course”, it was 3 days!

It's the human touch we need at this time.
Im all for the straight facts being given, but I've been on the receiving end a few times and without doubt, the Consultant who said ' its crap news Flicitytricity, im so sorry' wins out every time. It felt as though he really cared, as opposed to i was just another person with cancer he needed to tick off his daily report.
There's never going to be a great way to deliver bad news, but just seeming to really care goes a long way.

The doctor that told me my toddler had a brain tumour was very kind, and I almost remember that conversation in slow motion. Then she sat with us and played with our daughter and read to her until thr ambulance came to transfer her to the hospital which we called home for the next couple of months. Nurses hugged us even though it was covid times. The tumour thankfully was treatable and she's still with us, relatively well and we still see the kind doctor at check ups.

I needed her gentleness and kindness at that point. I also needed the absolute bluntness of the neurosurgeon 6 hours later when she was take into risky surgery when I asked point blank whether she'd die if she didn't have the surgery, and his single word response of 'yes'.

They were good at reading what we needed at that point and being clear. I'm glad that they didn't need to have that other conversation with us, but if they had, I know they'd have handled it a week as anyone could. Sadly I think they were well practiced in both conversations.

As others have said, it's not just about the words or tone but the wider situation and how that is dealt with. You may not be responsible for supporting the person with the aftermath of the news, but if there are organisations who do then you should be sharing that with the person or having them lined up.

Receiving bad news is never going to feel good, but if it's done carelessly it can needlessly traumatise people. Done well it can make them feel cared for and enable them to cope better with the situation.

My experiences of traumatic bad news delivery were largely about the wider situation not the script used when being told. Although the callous delivery didn't help.

E.g. Being given life changing news alone without any warning or suggestions to bring anyone and then being turfed out into a corridor in a state of shock without so much as a leaflet about where to get support - whatever script was used during the conversation, that's just a shit way to give bad news.

E.g. Overhearing clinical staff discussing (gossipping about) your prognosis before anyone comes to talk to you directly - also shit.

Is it an appropriate setting. Does the person know how serious things are. Have they been given an opportunity to bring someone with them. What support is available to them afterwards. How are they going to get home safely if they're in shock. Will anyone follow up with them. Are you treating them like a person.

Basically. Treat them like a human being who will continue to exist after the conversation, not a task you are lazily checking off your to do list. People notice when they're being treated like a task and it is damaging. And don't make it about you or your feelings if they're not grateful for your efforts in telling them something horrific.

Yes yes, I agree.

My much loved, very elderly relative went into hospital with a suspected broken bone and then went downhill very quickly (hospital acquired pneumonia). Due to her old age I feel the way the doctors talked about her was very cold. We were told causally (without having been told before that how ill she actually was) that “she’ll probably die soon but she’s had a long life”. On one occasion I was asked why I was so upset, as if I was being unreasonable. I would have liked more awareness from the doctors that even though yes, she was indeed extremely old, she was still a person, and was immensely loved (and now immensely missed).

Alternatively, do what our local Urology Department did and tell your patient they have metastatic cancer in a two paragraph letter!

One way I have heard that was helpful was to parents of a child moving to palliative care. The doctor explained that the focus of care now shifted to pain relief and patient comfort rather than aiming for a cure at the expensive of quality of life.
However I’m not entirely sure that they had been left clear that there was no opportunity for a cure. So I would do a mix of the PP but then follow up with something like the change of focus conversation.