Thursday, January 11, 2007

Breaking Bad News, Part II

Since making this post about the lecture we had on giving bad news, followed by a standardized patient encounter (in which I did fairly well), I've had lots more experience with it. I've seen a couple of different styles of news-giving.

My second medicine attending, Dr. C, was a heme/onc specialist. After examining her neck CT, I saw him tell a woman that her chemotherapy hadn't worked, that her tumor had continued to grow, and that it was now her decision whether to continue chemo or call home hospice. She cried. He repeated himself a lot, spoke calmly but empathetically; I believe he even held her hand.

My first call night on neurology, a man came in with a massive pontine hemorrhage. Virtually his entire brainstem was wiped out. I walked in to find the resident talking to his wife. We walked out to look at the CT, then we walked back in, the resident said simply "It's really bad. If there's anyone who needs to come see him, I'd have them come see him tonight, because it's possible he won't make it through the night." His wife cried. The resident apologized for giving her such news, and then we walked out.

My first neuro attending had to explain why he put a medical DNR on a comatose patient. He repeated himself over and over, because the family didn't understand at first. They thought we meant "we're withdrawing care", not "we won't resuscitate in case his heart stops again." Even though we were in the middle of rounds on a Saturday (and we wanted to get the hell out of there!), even though we were in the middle of a hallway, he continued the discussion until the family appeared to understand. They thanked him.


There will always be bad news in medicine. I'm not sure I can be as *cool* as these doctors in the face of such raw emotion. Every time I see a radiology report with cancer, it's almost like I hear the "DUNH-DUNH" from Law & Order, or church bells, or some other very somber sound. I appreciate these doctors' examples, and I want to learn this skill. I just hope it's possible to learn this skill of communicating effectively and sympathetically, without either continuing to bring it all home, or going the opposite direction and becoming hardened by it all. I am inspired by these doctors, however, not to run from such things. All of them took it upon themselves to deliver bad news; none of them tried to run away, or shirk this responsibility. I admire that, and I think that if I can learn how to do this, I can be a good doctor.


basia said...

i really liked how your first neuro attending would talk with the patient's family during rounds. yea, it makes things go longer, but it is what the family needs.

Jenn said...

I liked it, too. I really appreciated how there was always time for that, no matter how busy we were (and I'm not being sarcastic, even though it kinda sounds like I am).

Jessica said...

Hi jenn,
Thanks for leaving a comment on my blog - it must be my need for approval. *sigh*
When you did your pediatrics rotation did you see any parents get bad news? I saw a really old doctor give a mom some news on her kid that was totally not expecting. They had come in to get the 4 year old's murmum checked. Turned out he had third degree heart block. The old doc explained it really poorly once and that was it. It was awful and heartbreaking.

I didn't see it on your list of blogs, and since you said you were interested in OB, "Midwife With a Knife" is a great one. Also, she had some rough cases lately and has had to give bad news. Here's the address:

frectis said...

Midwife with a Knife has been dealing with the delivery of bad news lately herself.

Jenn said...

Thank you both for the recommendation--her blog is excellent!

Anonymous said...

i clicked on the link for midwife with a knife and was directed to bible prophecy/end times page.

was that a joke or intentional religious subterfuge?

i won't be back for more of that, thanks, anyway. i hope sick or dying patients and their loved ones aren't being ambushed with all that.

Jenn said...

I, too, clicked the above link to MMWAK and got some crappy website. I had to find her through Google. And speaking of religious stuff being forced on loved ones of dying patients, I found a Jack Chick tract in the ICU the other day. I accidentally threw it away.

Deirdre Bonnycastle said...

I would like to use this post and the linked one in a manual for residents about how Blogs can be used for reflective writing. Please contact me. Your anonymity is guaranteed.