The hardest part

TO BE a doctor is a privilege but with it comes responsibilities that can be onerous, to say the least. If you have ever talked to a friend outwith the profession about breaking bad news they will likely have shaken their head and said “rather you than me”.

This is a difficult part of the job but it also offers a chance to make a difference, to really be a doctor. It’s a defining point in the remainder of that person’s life. True, their personality, family support and other elements will affect how they deal with the news, but you can affect in what direction they set off.

We need to talk

The imparting of bad news is a skill that must be learnt and honed. Medical schools and post-graduate college exams have focused more on communication in recent years which is evidence of the recognition – albeit belated - that such skills are central to our work.

It may be awkward, but the only way to learn is to watch those who are more experienced. Like any other skill in our profession, you must observe and note good practice that you would hope to imitate. You must be in the room when bad news is broken, as unobtrusively as possible and only if the family and patient have no hint of an objection.

Be prepared

Neither the doctor nor the patient should ever be unsupported when ill tidings are in the air. This may not always be easy for a doctor in general practice, but in hospital a nurse or other colleague should always be there. They may help if you falter and, if you have to leave, they can stay on. This allows a feeling of gradually withdrawing rather than a wholesale, “Right that’s the way it is, we’re all off then.”

If an interpreter is required, make sure they will be there and discuss the salient points with them in advance. You both must be prepared and think about how they will phrase things and what words they will use. Remember, they may have significantly less training and support in breaking bad news. You may feel the news is coming from you but it is the interpreter’s words they will hear and it is to them that they will turn and direct questions. Do not forget how the situation may affect the interpreter. Facts of the matter The Oxford Handbook of Clinical Medicine (the infamous ‘Cheese’n’Onion’) is one of many sources offering advice on breaking bad news and there are others online. The key elements are constant:

• Introduce yourself and be clear and concise if asked direct questions. If you have never met the patient before and you are asked: “Are you one of the doctors who looked after my Dad?” explain that you are not but that you are the doctor working this evening and you did not want the family to be kept waiting.

• Always use clear and direct language. Avoid euphemisms because the embarrassment and hurt that can be caused when details are misconstrued can be more damaging than the natural grief and distress caused when the plain facts are made clear.

• Have a plan for further meetings, referrals or palliative care treatment. This gives a more positive slant to the close of the meeting. Always document all such encounters and the salient points in the medical records.

We did everything we could

Breaking the news of a death follows a very similar pattern. If you do not already know the family, it is essential to establish their knowledge of the seriousness of the illness or trauma. When you state that the person has died do not rush to say any more than “I’m very sorry.” Even if the news was expected there must be some time to allow it to sink in and nothing you say in those first few moments will be taken in.

Do not be tempted to go into great detail unless the family request it and question you. A further meeting later that day or the next may be the time to discuss matters in depth. I have seen families in bleary bewilderment whilst someone tries to describe in detail why the emergency surgery was unsuccessful. Anatomical terms, operative equipment, procedural names, the whole works are rarely appropriate.

It hurts me too

News of a terminal illness affects the patient, their family and friends, and you. Do not forget you. You cannot tell someone they are going to die, whether you’ve known them a year or a day, without feeling its impact. You may relate it to a friend or relative, to a previous case or you may play out imaginary and upsetting scenarios of how it will affect their family. Even avoiding thinking about it shows it is affecting you and, more importantly, that you are not dealing with it.

Patient confidentiality must be maintained, but you can still talk to friends or colleagues about a difficult day or having to tell someone terrible news. Do not feel that you must shoulder the burden alone. It is natural to be upset and disheartened so take a few minutes before carrying on with the rest of your work and be aware it may preoccupy you throughout the day.*

Don’t avoid these situations and have someone else break the news. This is a key part of being a doctor and goes hand-in-hand with the privileges of being so intimately involved in caring for people. Developing these skills through reflective practice will help improve your confidence in such emotionally-charged settings and further your professional development.

Dr Tom Berry is an StR 1 in Surgery in Glasgow and a BMA Scottish Junior Doctors’ Committee representative

MORE INFORMATION

• National Council for Hospice and Specialist Palliative Care Services: http://www.ncpc.org.uk/

• Breaking Bad News… Regional Guidelines Feb 2003: www.tinyurl.com/qcfm3v

• Communication skills cascade in health care: www.tinyurl.com/kv56js

*Doctors for Doctors: Should you find work-associated stress overwhelming, contact the BMA’s 24-hour confidential counselling service for medics and their families to discuss personal, emotional and work-related problems. Call 08459 200 169 or access www.tinyurl.com/m2u6zv for more information.

Breaking the news

BEFORE

• Adequate time allocated

• No bleep

• Know the facts

• Prepare for obvious questions

• Privacy for discussion

TO BEGIN

• Do they know why they are there?

• What do they know so far?

• Simple straight facts

• No overload of info

• Clear language

IN SUMMARY

• Written material if appropriate

• Clear contact details if any questions

• Perhaps plan to meet again