Part of being an oncologist is breaking bad news to patients and their families. But what I considered “tough talks” has evolved over time.
- Med student – asking about sex, drugs, and rock and roll were super hard.
- Intern – asking about whether the parents of a patient with a likely autosomal recessive disease were related, and then how.
- Senior resident – taking care of trauma patients in the PICU and having to tell their families that they were brain-dead.
- First year fellow – telling a family their child had cancer.
- Second year fellow – telling a family I’d become close to that their child’s cancer had relapsed.
- Third year fellow – telling a family that none of the therapies we’d tried worked, and their child is dying.
I would vote that these conversations will never be “easy.” But there are a few things that you can do to make them “less tough.”
You need to be in the right frame of mind at the right time. That means = don’t rush it. Make sure you have all of the info that you need before you head into a conversation. And if a family corners you before you’re ready – politely defer the conversation to a later time. Ex) “This is a really important conversation that I want to have with you, but I would like to be more prepared. Can we meet back up later today/discuss at your next visit…(whatever fits)”
If you know that you are headed in for a tough talk – warn your nurse/etc that you will be in there for a bit and you do not want to be disturbed.
For informed consents – ALWAYS review them one more time. Unless you have gone through that exact consent recently, it is best to take the few minutes to see what is where.
Avoid medical jargon as best as you can – always make sure to elicit questions and check for understanding by the patient or family. On that note, avoid information overload – remember to pause after giving bad news and let it sink in.
Sometimes the conversation naturally progresses into a tough talk. When you are seeing a patient in clinic whose cancer has relapsed or is refractory and they are not doing well (pain, fatigue, etc) – it can be easy to segue into a tough talk. Other times, you may have to approach the “what if’s” with a family even if they aren’t asking the questions yet. I start by saying “It know it is hard to think about these possibilities, but I feel that it is my job to prepare for any issues that may arise… ((here)) are the issues I am worried might happen, and ((here)) is how I think we can help…”
Truthfully there is never a “good” time to give bad news. When my cousin was battling metastatic breast cancer, she complained to me about how her doctors wouldn’t call her at the end of the week with bad news. They would wait until Monday. She finally approached them about it and they said that they wanted her to have a good weekend without the burden of the bad news. But her experience was quite the opposite – she would stress all weekend assuming the worst, go to work on Monday, get the bad news call, and have to take off the rest of the day to compose herself.
Privacy, privacy, privacy!
In the infusion room with just a curtain between the patient “rooms” or during walking rounds outside of a patient’s room – not ideal! It’s much better to find a quiet and private place.
Sometimes we are asked questions in the moment, questions that open doors to tough conversations the family wasn’t willing to have before (or sometimes the med students/residents accidentally open the door…). Gauge the situation and start the conversation, but you can try to step back and offer to have the conversation later. Especially if emotions are starting to take hold in a not so private location.
In Summary: Tough talks will always be tough. But with some preparation and practice we can get better at it.
What are your tips for having tough talks?