Delivering Bad News

One of the best classes I enrolled in while in grad school was Death and Grief, a Social Work course. This course allowed me to assess my own feelings about death and grief, and how I would help patients going through both of these natural life occurrences. Dr. H was a wonderful professor, and she really helped me to see things differently. Of the things she stressed to the class was that patients and families often times were not prepared for the bad news their doctors would bring, and doctors were not really “taught” to deliver bad news but had to learn on the fly during their training, so any additional training and preparation that we had (I believe I was the only student who was in the BETH program, in a group of SW students) would benefit our patients. On more than one occasion, we were able to pair up with a classmate and discuss our own grief, whether it be past or present, and about loved ones that we had lost. It was a very moving experience, since I had never once before really thought about how I processed my own grief or thoughts of death.

I do want to mention that this class was not morbid or disturbing. Our main focus was to be able to help others by being compassionate, understanding, and comforting in their time of need, and to do our best to ensure to the best of our capabilities that our patients got a “good death”. As a Bioethics student, many of our cases involved end-of-life dilemmas, and I feel that understanding a patient’s or family’s point of view has made a huge, positive impact on how I think about discussing options with them, when the time comes.

It was a wonderful, marvelous, eye-opening experience, and I am so very glad I used that course as one of my electives. I also read a book (yes, for fun) that most would probably think is strange or gross… Body of Work by Dr. Christine Montross, about her reactions as an MS1 (first-year med student) in a Gross Anatomy class using cadavers, in which she also details her own research project into the history of body donation for medical purposes. On more than one occasion during all of my shadowing and volunteering in hospitals, I’ve had several patients die and I’ve helped prepare the body for transport to the morgue. In my mind, I have a good idea of how I deal with death, dying, and the grief of both the patient and the patient’s family. (One of the reasons I decided to become a patient volunteer through hospice was to get the opportunity to become “someone’s last best friend.” Everyone deserves a good death, and a companion through the dying process, as death is a part of life.)

So now that I’ve had all of this training and experience, and have thought about what I would do when the time comes, in order to prepare myself… let me tell you about a time where I was completely unprepared.

Dr. S is a practicing urologist who I had the opportunity to shadow while I was in graduate school. He is absolutely wonderful, and I love him to pieces! He’s the epitome of what a good doctor should be: compassionate, determined, and friendly–not what I expected from a surgery sub-specialty, but I was pleasantly surprised at his candid nature. I learned so much from him in just a few visits, even though I had never even thought about shadowing in urology before. Most of the cases we saw were either prostate or bladder cancer (even if you quit smoking or dyeing your hair, you’re still at risk for bladder cancer!); I even got to look inside someone’s bladder at a tumor, and use a machine that could tell you the amount of fluid in someone’s bladder from scanning their lower abdomen.

Before we entered each patient’s room, Dr. S would give me a brief introduction to the diagnosis, next steps, treatment options, or patient concerns. After seeing several cancer diagnoses and how well Dr. S had handled patient questions and concerns, I began to appreciate how he assured each patient that there were several options that they could discuss; most of the cases that I saw were caught early, so the prognoses were, in general, good.

There was one patient’s chart that looked like many others I had seen during my time in urology. This patient had prostate cancer, and Dr. S was confident they would be able to treat it successfully and the patient would be okay.

When that door opened, I entered this room under the assumption that the patient was already aware of the diagnosis. I was wrong. And I was not prepared.

In all of my time in hospitals, I’ve seen so many things. Emergency appendectomies, emergency cardiac catheterizations, a splenectomy, amputations, a hysterectomy, severe birth defects…. I could go on and on, and I ate it up. I love the art of diagnosis, of seeing something I’ve never seen before, of learning about something new and the steps to correct or alleviate the issue. This is what I live for, how I want to make a difference in this world. I take pride in keeping my emotions to myself and seeing the patient as a person, in order to make him or her feel comfortable in my presence. I never want a patient to feel uncomfortable, or like I am looking at him or her as a disease, or staring at the affected limb or body area. I tend to take it all in stride, without blanching.

Or at least, I did before that day.

This patient did not have anyone with him when he came into the office. This patient did not know what the test results had shown. As I heard Dr. S explain that the test results were not good, that they indicated he had prostate cancer and there were several options for treatment, that he was confident that they could eradicate the cancer and he could live a long and healthy life…. I remember taking a quick, deep breath in when I realized this was the exact moment a cancer diagnosis was being made, and immediately feeling tears start to well up in my eyes. Time was going by at an ever-so-sluggish pace that felt like an eternity. I tried to act as professional as possible, but I was overcome. The patient sat with his hands clasped together, looking down at the floor and not at Dr. S or me. He had a look of concern on his face and his forehead was scrunched, his mouth open in a silent “o”. When he finally looked up at Dr. S he said, “So I’m going to be okay?”, and I saw there were tears in his eyes as well.

Dr. S assured the patient that since it was caught early, the prognosis looked to be good, and he foresaw no complications. From my experience, when a patient is diagnosed with something with bleak outcomes, especially cancer, the patient may be in such a shock that he or she doesn’t really hear what the physician is saying, as the bad news has not had adequate time to adjust to what he or she just heard. It tends to be worse when the patient has no family or friend accompanying them to reiterate what was said. Dr. S kept reassuring that they could go over all the possible options for treatment several times, allowing time for due process and for the patient to fully comprehend what just happened.

As we left that room and prepared for the next, I felt as though I was still in shock. I hated to leave him in the exam room alone. What I really wanted to do was to just stay behind and hold his hand; a comforting touch can be somewhat healing in itself. However, since we had a busy day with a hallway of full exam rooms, I had to press on, on the heels of Dr. S. Not having a nursing or medical license (or even completed my Bioethics degree yet, at that time), I really was not qualified to be alone in the patient’s with him to comfort him, no matter how badly I wanted to be there to offer comfort.

As I type this, I can feel the tears coming back. I think I will always carry that memory with me. Dr. S carried himself with such grace and poise, and even went back to speak to the patient again, after some time had passed to reassure him once more. I have often thought about that experience, and hope that in the future when it becomes my turn to share bad news, that I am able to muster the same poise and compassion.

Dr. S is wonderful. I am so thankful for his kindness in allowing me shadow him in his practice; I learned so much in just  a few short visits and someday I hope to be a competent physician just like him.

“Great multitudes followed Him, and He healed them all.” Matthew 12:15

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