Delivering Bad News

My heart began pounding as I listened to the sound of the dial tone in my ear. After three rings a woman answered groggily and uncertainly, "H-hello?"

"Mrs. Peterson?" I asked. My voice trembled slightly. It was 2 a.m. and I'd awakened her from what I imagined had been a troubled sleep.

"Yes?"

"This is Dr. Lickerman. I'm calling from the hospital." I paused. "I'm calling about your husband."

There was silence. Then a breathless, "Yes?"

"Mrs. Peterson, I'm the resident on call taking care of your husband. Your husband--your husband's suffered a complication. You know the heart attack he came in for was very serious. A large part of his heart had stopped working. Well, Mrs. Peterson, I just don't know how to say this to you but...your husband passed away tonight. We tried everything we could to save him but there was just too much damage to his heart. It just couldn't keep pumping blood. I'm...really sorry. I don't know how--I'm just really sorry. I wish I weren't telling you this over the phone..."

A few more minutes of silence passed, and I realized she was crying. "I understand," she said finally. "Thank you." Then she asked, "What do I do now?"

Relief coursed through me. "There's a hospital administrator on the line--"

"Hello," the hospital administrator said gently.

"--he's going to explain everything you need to do." I paused. "Mrs. Peterson, I am just so sorry..."

"Thank you," she said quietly. When I hung up I found my hands were literally shaking.

I was a first year resident, and this was the first time I'd ever had to tell a family member a loved one had died. It had happened in the middle of the night so I'd had no choice but to deliver the news over the phone. Not only that, but because I was covering for another resident and had only met Mr. Peterson that night after his heart had stopped and I'd been called to try to resuscitate him, his wife ended up hearing the news of his death from a total stranger. It was an experience I will never forget.

DOING IT BETTER

In the years since then, I've had to deliver that kind of news to families a score of times and bad news of a slightly lesser magnitude hundreds of times. In all honesty--and contrary to the popular saying--it has in fact become easier, partly because I've learned to do it better, I think, and partly because the more you do anything the less it stirs up the initial emotion that accompanied it. What follows is the approach I've developed over the years to deliver bad news in the most compassionate manner possible.

Prepare yourself to feel badly. Doctors enter medicine with the hope of making patients feel better. However, when delivering bad news, that's not what happens. No matter how people feel before I give them bad news, afterward they always feel worse. If I don't recognize this as normal, that working hard to make people feel good about bad news is not only counterproductive to the grieving process but potentially deleterious for our doctor-patient relationship, in the long run I'll add to my patients' pain rather than diminish it.

Set the context. When delivering bad news of any kind, providing the recipient time to prepare themselves can be helpful. My attempt to do this with Mrs. Peterson was clumsy ("You know the heart attack he came in for was very serious"), but my intent was honest: I wanted her to realize I was about to tell her something awful. The phrase "brace yourself" carries more than a metaphorical meaning in this context. Psychologically, even a single moment of preparation can mute the pain of hearing bad news, if only a little.

Deliver the bad news clearly and unequivocally. I don't say, "There's a shadow on your chest x-ray" or "You have a lesion in your lung" or even "You have a tumor." I say, "You have cancer." The temptation to soften the blow by using jargon is surprisingly powerful but extremely detrimental. At best, it delays the patient's understanding of the truth; at worst, it promotes their denial of it.

Stop. When a person receives bad news, they always have some kind of reaction. Some cry. Some get angry. Some sit quietly in numbed shock. Some refuse to believe what they've been told. My job at that point, however, isn't to clarify, mollify, restate, or defend the diagnosis or myself. My job is to respond to their reaction and help them through it. I vividly remember the first time I had to tell a patient and his family he had lung cancer, some time after my late night call to Mrs. Peterson. I came into the room to find ten or so family members gathered around my patient's bed. I set the context, I delivered the news clearly, and then I launched into thirty minutes of clarifying explanation. When I finally paused to take a breath and to allow my patient to react to what I'd told him, he only looked at me with a sad expression and mumbled in a subdued voice, "I thought I had more time." He hadn't, of course, heard a word I'd said after I'd said the word "cancer." The only person I'd been attempting to treat with my soliloquy had been myself.