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?

Look them in the eye and tell them, my dr looked at their computer the entire time which was wtf and just felt rude and dismissive. I was a person getting devastating news not a cell on an excel spreadsheet or whatever

From my specific situation when finding out my son had cancer and also several times when they didn't expect that he'd survive.

Timing. Is it really necessary to tell the parents of an already critically ill 8 year old that he has cancer at 10pm on a Friday night when the parents are far away from home and will have no professional support over the weekend?

Communication. I was told after the fact that it was looking likely it was cancer for a good few days before I was told and I would've appreciated the heads up. I was initially told it might be cancer, then I was told it was unlikely to be cancer and then I was suddenly told it was cancer. I would've liked to have been warned that it was looking more likely that it was cancer though I do appreciate not every parent would've felt that way.

Every time I was asked to go to a private room, I was terrified that I was been told that there was nothing more to be done. I would've maybe liked a quick ''we're just going to discuss'' instead of leaving me guessing and convinced they were telling me my child was about to die.

Honesty. It didn't look good several times with my son and I was always told this and never given any false hope.

Regular updates/meetings as he had several things going on and this was before his cancer diagnosis. All of the information made me feel slightly less useless and out of control.

Never take the risk of assuming someone doesn't know what an oncologist is. I was told that they pretty much guessed I'd know what one is so they didn't send her straight away but it would be a pretty awful way of finding out if you or your child has cancer.

For me, I’d want a doctor to be empathetic but also be straightforward in what they’re saying. I want facts, treatment options and possible prognosis.

ive got a few medical issues and my ‘favourite’ consultant is one who listens to me and will refer to a colleague if appropriate.

So I’d say ‘I’m sorry, but ….’ - give clear info, have you got any questions for me, next steps are ….heres my email:secretary’s details if you think of anything else.’

My DS is a doctor, in the US. He was given extensive training in patient communication in the course of his studies.

His med school hired actors to present with various 'symptoms' and the students were supposed to ask intelligent questions in a kind, non-judgemental, and professional way, and then come up with their response/ diagnosis / explanation of what further labs or testing needed to be done. Small but basic elements of patient contact were drilled into the students - like a warm and polite greeting, a handshake, strong eye contact, being familiar with the patient's record before entering the exam room, making sure he pronounced the patient's name properly, letting the patient talk and not cutting in with a question...

As a resident, learning his specialty, he was further coached by his seniors in communication. Basically, he learned to gauge or assess the sort of personality he was dealing with, and their anxiety level as well as vocabulary / level of intelligence, and wider experience of life in the first two minutes of conversation, and to go from there with his manner.

As a med student, the male patient actors mostly gave feedback that they appreciated DS's candour (bluntness), and the women said they would have preferred a bit more hand holding. This he worked on.

He learned as a resident that he really needed to tread carefully in some areas, while a candid approach worked well in others. Generally speaking, if a condition was related to patient weight or lifestyle (high cholesterol or type 2 diabetes related to junk food, booze, smoking) issues related to drugs, and easing off the substances or losing weight would make a difference to health, he had to be very tactful, while for a diagnosis of cancer or an acute condition, a factual approach was usually appreciated., along with, "I know that's a lot to take on board, so we won't rush through this," followed by recommendations for labs, treatment, etc, and then listening to questions from the patient, answering kindly even if a question was repeated or based on misunderstanding the info.

I think for me there's the run up point to it. 'So by looking at your scans, what we can see here are (facts), there's an indication that etc.'

There's tone of voice - calming but serious. And body language is important, facing, eye contact. Using their name. But it may be different between cultures.

There's definitely an emphasis on brisk and efficient in the times I've had bad news. But you have to remember that once you have said the news no one is hearing what you are saying anymore. They're thinking about that one word you said and what it means for them, whether that's uncertainty, impact on work, family. So letting them have some time to digest and time to ask questions. Do you want to call someone etc. Or do you have someone with you etc. The one thing someone might just want in that time is a hand over theirs or a hand squeeze.

Age might be important e.g. starting with the positive. I think younger people need more hope.

The most important thing is that you are the conveyor of facts and the plan and advice.

I've had a radiologist say 'the doctors will see you immediately' while opening the door. I've had a consultant briskly without fully closing my cubicle curtain tell me my (organ) was covered in (abnormalities) and it was 'some rare medical thing'. So the privacy and body language part go hand in hand for me.

I’m not a doctor.

but I was a teacher for a long time.

I’d suggest that rather than having a single way of doing it you try to gauge the personality of the person in front of you (and maybe take into account their journey if you have time to read the files).

at the most basic level there are people that appreciate (very!) straight talking and people who don’t

The way I was told DF was dying has stayed with me ever since - being told in a rushed manner ‘well clearly you know he’s terminal, so you have to tell your mother’. I really didn’t know and would have appreciated a discussion with the whole family. We’d all been at his bedside for a couple of days, so why they grabbed me when I left to get a coffee, I don’t know. It was also in a large cancer hospital so I would’ve expected much better. The lovely registrar who had witnessed it and followed up with us all repaired the situation somewhat. English wasn’t his 1st language but he did a much better job of ‘the talk’ with the whole family and was a comfort to me that he signed the death certificate and not the awful consultant. Don’t assume that people are aware or expecting the news, even if they have some health background.

My late wife was given her terminal diagnosis early in the morning, the day after a scan as an inpatient. There was a note on her file from the previous day (so not lost in the paperwork of many months) stating that she did not wish to be given the results of her scan until I was with her, as she had cognitive and memory issues resulting from the Parkinson’s she already had, and would be unlikely to properly retain the information.

The consultant, however, didn’t read that, or chose to disregard it, we will never know, and told her she had pancreatic cancer with secondaries in the liver and lungs, and it would be ‘extremely unlikely’ for her still to be alive in 6 months’ time. He then walked out of her room and left her alone with that information. She called me in acute distress and I hot-footed it to the hospital.

My wife was unable to remember much of what the consultant had said, and the nurse who had been with him didn’t want to answer our questions (understandably), so the consultant had to come back and tell both of us what the situation was and what the next steps were. He was visibly irritated that he had had to make a second visit to my wife with the same news (lots of ‘as I told you earlier’ to my wife) and when we asked about treatments, palliative care, etc, (grasping at straws really) he said - and this is a direct quote - ‘don’t go away from here with any hope, because there isn’t any’.

OP, you ask how doctors can ‘do this better’. They can recognise that no two patients are the same, they all come with their own unique circumstances and situations, and when a patient has expressed REALLY CLEARLY how they wish difficult news to be communicated, you respect their wishes. A doctor will presumably have to deliver distressing news potentially dozens or even hundreds of times during their career, each patient will receive the news of their impending death once.

I would strongly recommend you have some kind of sheet to hand them with some basic details of what you've said, charity helplines, PALS, etc. Often questions occur to people afterwards and they may not understand key terms that are normal to you.

An example from teaching: a lot of parents don't understand "KS3".

The consultant who told DM she had cancer didn’t look at her and glossed over it, before leaping into the treatment plan. It was like he knew what was up with her, and he expected her to know too. She was very confused. I had to tell her what he meant.

This would be useful.
I think the ability to hold words in your head fade when you're given bad news.

And to know what the next steps are likely to be.
ie: whoever will contact you, and it'll be by phone/post/email ..

And be aware that a lot of people are deaf, and didn’t hear you properly the first time.

There is no easy way to do it. I would just say be clear, don't beat around the bush.