Thursday, January 06, 2005

Bad News

Giving and not receiving. Not yet.

Yesterday I gave two patients bad news. Like about 50% of medicine, I really don't like doing this. Good news is simply good, patients take it as their due, as if they expect nothing less. Just give it, "nope, all information indicates that your problem is fixed." It's taken easily. Taken almost for granted as if the patient knew that it couldn't have turned out any other way. But then there's bad news. That's different.

Both of the cases were the same. Both had an essentially untreatable, progressive, and ultimately fatal disease. Sucks. Oddly, neither family expected, or seemed to expect, the news. Usually you do get a glimmer that the nature of the problem crossed the family's mind when you ask what they've been told about the problem in the past. But yesterday the wife actually said, "well, at least it's not ______." They didn't see it coming.

The formula they teach you as a resident and med student is easy. Nothing could be simpler. Just say it. Don't preface it with, "I'm sorry." Don't not say it. Don't avoid saying it by softening it. Just say it. " The diagnosis is ALS." Or HIV. Or cancer. Or Alzheimer's. The bomb drops, that's it.

I always had problems with the lack of "I'm sorry." Turns out saying that is the worst thing to do. If you say sorry, they why are you sorry? Did you do something wrong? Are you telling them you pity them? Are you apologizing for something? As it turns out, saying I'm sorry creates the sense that the news is even worse than it is. And that sets up tears and tears are not useful and waste time, which is the cardinal sin of medicine.

What they don't teach you in med school is what to do during the silence that follows the drop of the bomb. The fragments are still exploding in each of your audience's brains. You can't hear it, but you can see it. If you look you can see the raised eyebrows, the widened eyes, the nervous crossing of arms. That's hard to watch, so I look away. But I can't retreat to Doc NOS land, revisiting a pleasant moment, the time I kissed my daughter and she said something that resembled I love you. Or the first time I surfed (HI). I have to prepare for the next question, because it's coming. So I wait. At the ready. I don't have so much as a thought or a process in my head as I have an expectation and a preparation. A certain prepared manner of speech designed to be rational and comforting, which I would never use with anyone in my real life.

The question came. As it always comes.

The question following the bomb is small. Sometimes meek, sometimes falsely jovial, sometimes even angry, but it is almost always a small quesiton. Composed of small words within a small sentence, it is always a question. Questions demand answers.

"Are you sure?" Yes.

"What does that mean?"

"But he seems OK now?"

Or the wife asks her husband, "Don't you have any questions?"

Rarely, "How long?"

It seems no paragraphs can be built on rubble.

Each patient took the news well. As did their families. They actually always do. At least when they're with me. I suspect the tears come later, the anger, the anguish, the sense of waste. Later still comes the suffering. And later still comes death, accepted or not, reconciled or not, house in order or house in disorder.

To me it's a day. Yesterday two, today none, tomorrow perhaps three. I go home and go for a run. To them it's one of the worst days of their lives.

One day it'll be one of the worst days of my life. When I get the news I just want them to say it. I don't want them to avoid it. And I want them to say they're sorry. But when I don't hear it, I'll know that they really are. Just as I am. Deeply sorry, deeply unhappy, with great sorrow, and more so because I can't say it.


Anonymous Anonymous said...

wow. nice post.

4:31 PM  
Blogger Jean-Francois said...

I'm sorry Dude.

When I worked in human resources, the feelings before, during and after laying off someone, was pretty much like the one you described. No 'Im sorry' allowed, even though I was sorry.

2:47 PM  
Anonymous Anonymous said...

HR is all about management interests. Sorry? Please! We're all adults here.

9:30 AM  
Blogger laurenbove said...

I wanted to say: "Wow", but it was taken.

2:30 PM  
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