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Tuesday 12 December 2017

Breaking the bad news

You have cancer. It's terminal." My father, who died last month, was so distraught upon hearing these words that my mother never felt able to ask him whether he thought the consultant's bluntness was inappropriate.

Nor did she ask my father whether he considered it bad practice that he was told at 9pm, immediately after which my mother was asked to go home because "visiting hours are over". Or whether my father found it tactless that, when he asked the consultant whether there was anything they could do for him, he was told irritably it was too late in the evening to discuss.

Back in 2001, when British journalist John Diamond, the late husband of celebrity chef Nigella Lawson, wrote about his experience of throat cancer, he could hardly believe that so many doctors who regularly have to break bad news to patients had not yet found a way "somewhere between the mawkish and the unnecessarily brusque".

There was, it turned out, a woeful lack of training, despite the fact that virtually every clinical speciality requires doctors at some stage to be the bearers of difficult news -- anything from informing someone that their child has irreversible brain damage to telling someone they're going blind.

The focus is, of course, on the patient, yet let's not forget how difficult breaking bad news is for doctors. Dr Illona Duffy, who writes for the Irish Medical Times, says: "It's awful, as a doctor you want to fix things, and when you're breaking very bad news, you're saying, I possibly can't fix this. There's a terrible feeling of powerlessness."

It matters, says Lesley Fallowfield, a professor of psycho-oncology, because research shows that an insensitive approach increases the patient's distress, may exert a lasting impact on their ability to adapt and adjust to what they've been told, may affect their relationship with not just that doctor but all medical staff, and can lead to depression, anger and increased risk of litigation. Breaking bad news badly isn't good for doctors either, leading to feelings of failure, sorrow and guilt -- and studies reveal it gets no easier as they become more experienced.

One patient interviewed isn't convinced we should feel sympathetic to all doctors, however. "When I got to hospital to have a routine colonoscopy, I was shown to a treatment room, asked to remove my clothes and given no blanket, and the consultant walked in with three young medical students, not bothering to ask if I minded," she says. "After he'd looked at me, he simply said, 'I can see a growth on your bowel and I'm absolutely certain it's cancer. Put on your clothes and book a scan with the nurse.' Then he walked out."

The good news is that growing recognition of the problem means things are finally changing. Many of today's medical undergraduates and postgraduates are taught how to tell people what will often be the worst news they'll ever hear, and many existing consultants also get training. Anne Corbett, an end-of-life medical facilitator, admits that it's likely to be some time before stories such as my father's become rare. "Only 10 people can do the course at a time because it involves so much role-play and it costs thousands --a big chunk out of any training budget."



Feelings

Dr Illona Duffy believes there are steps a medic can take to protect a patient's feelings when news is bad. "Talking to a patient at the end of a clinic means you won't be interrupted; there isn't another patient waiting, a staff member isn't going to knock on the door for you to sign a prescription, the phone is off the hook.

"As a GP, a patient's immediate family can be in touch with you and you can take steps to ensure that a person isn't alone when taking in information regarding a diagnosis. Most of us will only take in 30pc of what we hear when we are in shock, so having someone there to write things down is a good thing," she says.

With international studies showing that doctors frequently censor information they give to patients about outlook, this has become a critical focus of courses. One US study showed that even if patients in hospices requested survival estimates, physicians said they provided frank disclosure only 37pc of the time.

There is, without doubt, a growing awareness of the problem however, and when it comes to delivering bad news, Mark Lansdown, a consultant surgeon, says that he has learnt to be more aware of his own mood. "If you've opened a letter of complaint or a colleague is off sick, the pressure can be enormous, but you must suspend yourself entirely from daily pressures when breaking bad news."

Dr Tony Calland, a recently retired GP, says it's key for doctors to be prepared, no matter how heavy their workload. "When it comes to breaking bad news about children, the GP is often the first to know and we have to organise the next step before you tell the patient and also try to make sure they aren't on their own."

Bad news being broken to patients without a friend or relative to support them is a particular bugbear for cancer information nurse specialists. Very often clinics in which bad news is given are held on Fridays, too, so patients leave the hospital for the weekend not knowing where to turn to.

When it became clear that my father was rapidly going downhill, I tapped the arm of a consultant doing the ward rounds to ask for an update. Despite the consultant being rushed off his feet and bound by patient confidentiality (my father never wanted anyone to know how ill he was), he took a pragmatic approach, taking me into the relatives' room and explaining that he felt it was important that someone in my family was informed he had days, possibly hours, left. He sat with me while I cried and answered every question I had truthfully and sensitively. It's hard to quantify exactly how his respectfulness and kindness helped, but there's no doubt in my mind that it did.

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