Delivering Bad News to Patients - A Primer

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Last week, I shared my thoughts on the essential physician skill of delivering serious medical news to patients. This week, as promised, I share a dialogue between me and a patient with some editorial comments intercalated in italics.  This is not a real patient, but the scenario I created is highly realistic and familiar to medical professionals and to many readers.

While I welcome reader comments of all stripes, please keep in mind that I did not endeavor to cover every aspect of this issue.  I tried to emphasize some major points.  Now, onto the vignette.

Comments of all stripes welcome on this and every post.

Joe is a 50-year-old man who is about to undergo a routine screening colonoscopy.  I’ve known him for about 5 years or so. After some light banter and the typical medical interviews, he was taken into the procedure room.   The colonoscopy revealed colon cancer hiding in the uppermost region of the colon. 

Life changes in an instant.  Joe’s life was about to experience an abrupt disruption that will jar his and his family’s equilibrium.   And Joe will have no warning, no opportunity to prepare.  Life can be cruel and unfair, but we are still tasked to deal with it.

Joe is now in the recovery area joined by his wife Louise.  The anesthesia has largely worn off.  I approach the bedside.

“Joe, I have serious news to share with you.”

I set a serious tone at the outset. This is not the time for a light moment or a casual remark which would delay the business at hand. While Joe is the patient, I make sure to have some eye contact with Louise also. Having a family member present is usually a great asset.

“We found a mass high up in your colon.  I believe it is a cancer, based on my experience, The biopsy results won’t be available for a day or two, but I expect that they will confirm my suspicion.

When I know the lesion is malignant by its appearance, having seen scores of them over my career, I use the word cancer in my initial remarks.  I don’t think it helps patients for doctors to avoid the truth, which will surely come out later.  False hope, which is destined to be extinguished, is not a compassionate approach.  I think that some physicians might adopt a more sanitized approach in an effort to spare patients, and perhaps themselves, from hard news.

“Joe, this is a very treatable condition and I will be with you every step of the way.  You will be in the hands of absolute experts in colon cancer.  I have worked with this team for years and they are superb.  If you like, I can arrange the appointments for you.”

This is the marrow of this initial conversation.  I assure the patient that I will remain engaged.  And most importantly, the patient and family will leave my office knowing that a plan for him is already in formation.  When possible, I arrange timely medical appointments for these patients while they are still recovering in the endoscopy suite.

“Doc, will I need an operation?”

“Yes, Joe, that is very possible.  The medical team will be recommending some additional tests and will then present you with their best advice on treatment options.  Surgery is certainly a possibility.”

“Will I have to have a bag?  My aunt had colon cancer and had a bag for the rest of her life.”

Even when a colon cancer diagnosis is first shared, patients have expressed this fear to me, which I can often assuage.

“Joe, because of the location of the tumor in your colon, I’m confident that there will be no bag in your future.”

You can appreciate Joe’s relief here.

“Joe and Louise, I know this is a ton of news that none of us expected. And it’s scary when we don’t have all the answers, but many of these gaps will be filled in soon.  Do you have any questions for me now?  You probably will later so please feel free to reach out.  I’ll give you call later in the week to make sure that everything is on track. 

Joe and Louise hopefully take comfort in knowing that I intend to serve as Joe’s advocate.

Patients and their families can only absorb so much.  For instance, Joe didn’t ask about chemotherapy, so I didn’t feel I needed to include it in my remarks to him. 

This is my general approach to delivering unexpected, unfavorable medical news.  Other seasoned physicians may have different strategies.  My guideposts are to tell the truth, avoid unwarranted optimism, affirm my ongoing role as the patient’s advocate, commit to recruiting medical experts to care for the patient and demonstrate authentic empathy.

Contrast the above approach with a leaner alternative. “There was an abnormality in the colon. Joe. It looks suspicious. I’ll call you next week when biopsy results are in.”

If you were the patient, which approach do you think would serve you better?

Comments welcome.