Thursday, 27 December 2012

Breaking bad news.

Despite everything I've learnt in theory, all the practical tips anyone has ever given me, and all the possible practice scenarios I could have done (although to be honest, we never did this in med school) nothing really prepared me for having to break bad news to a family.

It started out innocently enough as a routine "could you please speak to the family of patient X about the scan results?", a reasonable enough request and one that can often be deputed to a house surgeon. Normally family have an idea about the radiology results, anyway - bowel obstruction, fractured ribs, fluid overload, interstitial lung disease, old stroke changes, age-related changes, pneumonia - it's pretty damn difficult not to know at times, since it's usually to do with why they came in originally.

This one was not routine.

I glanced over the report so I would have some idea what I was talking about - the general feeling from scanning the notes was that it was a scan to rule out vs. to rule in.

I wasn't prepared for 'there are lesions with the typical appearance of cancer'. If you don't know what that means in terms of prognosis, don't worry. I didn't know either, apart from "months" and "not good" for this specific individual.

So of course I did what any respectable house surgeon would do in this situation, and immediately turned to the house surgeon next to me and went "Oh crap. What do I do now?" Fortunately (unfortunately?) there was an unsuspecting consultant sitting in the fishbowl as well, so up the chain of command we went, and determined that it was in fact okay for me to give this news despite having had absolutely nothing to do with the patient as yet.

"Hi, my name is ___ and I'm one of the junior doctors on today. I understand you wanted to know about the scan results. What have you heard so far about the scans?"

Nothing about what we suspected, nothing about the possibilities. I wasn't sure if they'd not been told or if we hadn't told them in a way they'd remember and understand. I'd gotten them to sit down already, closed the door, warned the nurse, made sure they were comfortable, made sure the patient wasn't overly distracted by nausea, pain, or needing to pee. There was no easy way to say it.

"I'm sorry, I have to give you bad news about the scan result."

Preparation. A warning. Building things up. We follow a process to give bad news. It has to be private. It has to be appropriate. You have to take time, make sure everything is okay, and then shatter the okay.

"The scan shows that you have tumours that look like they could be a cancer." (okay, not quite like this. but I don't want to give more details, and to write what I actually said would break confidentiality)

And then I was out of my depth.

People know that tumours are bad. They know some can be fixed, and that some can't.
I had to tell them that, most likely, this was the latter category.
I told them, when they asked, that, no, right now we can't do anything for the tumour itself, that we had to wait some more to find out what could be done.
I told them that yes, your loved one could get worse, and no, we might not be able to help it.

I shattered the okay in that room well and truly, and I felt like utter crap doing it. Afterwards, I hoped I hadn't fucked up, all the things they tell you about "not overwhelming them with information" and "giving them space" and "letting them come to terms with it". It is hard to sit in silence with strangers and give them space when you want to jump in and say something. It is hard to let someone else come to terms with something when you yourself don't want to be telling them that something. It is even harder not to be overwhelmed yourself.

Of course, none of this was in my head while I was there. As soon as I opened my mouth and the word tumours came out, I forgot everything. I'm not sure that I did a great job of it. I nearly cried when I was in there, hopefully hidden by the mood lighting and my glasses.

But I told them the news, and I left them with the news, and my pager number, and a damning piece of paper with the scan results. They thanked me as I left.

I'm not really sure what else to say about this. I don't want to go into the self-introspective "what did I learn what can I take away from this," I just wanted to share a story about sharing, and how it went for me, and what happened. The End.

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