Breaking Bad News….Badly
One of the situations I encountered in a surgical outpatient clinic impacted me deeply. The patient was an 89-year-old gentleman diagnosed with colorectal carcinoma. The doctor broke the bad news to the patient and his son, but the method he adopted was so different from the SPIKES framework that we have been taught in our clinical interpersonal skills sessions. Ideally, the setting should be quiet, but on that day the patient and his son, along with the doctor, nurse and two medical students were present. Simultaneously, another patient was being examined by a doctor in the same small room. Information was conveyed to the patient without first exploring his perception of his illness. The doctor just told him the diagnosis and moved straight to the treatment options.
The discussion on treatment options was the part that bothered me the most out of the whole experience. The doctor proposed two treatment modalities, surgical resection or palliative care. However, instead of focusing on the possible benefits of each option, he put emphasis on the drawbacks of each option. For example, for surgery, he reiterated multiple times that because the patient was of an advanced age, he had a very high risk of requiring a permanent stoma, may have increased risk of pneumonia or myocardial infarction, or may not be able to regain mobility after prolonged bedrest if complications arose. One would have thought that this was his method of persuading the patient not to take the surgery, but he moved on to say that if the patient decided not to have the surgery, he may have other complications like a further increase in abdominal pain, as well as intestinal obstruction or perforation which would also result in stoma creation and eventually death. He explained all these in a monotonous tone and spoke very quickly due to the large number of patients waiting for their turn to see the doctor. He finished by adding that if they decided to do the surgery, they should make the decision then, as there was a vacancy for surgery next week due to a cancellation.
It’s only when we realize that our primary role is to treat the patient, not the disease, that we learn to provide empathy and alleviate suffering.
I vividly remember the shocked expression on the face of the patient and his son after the doctor had ‘explained’ the two treatment options to them. They didn’t have time to digest the bad news before facing the immediate pressure of making such an important decision. As I was just a medical student attaching to the clinic for the day, it was not my place to say anything in that situation. However, I have not been able to get this consultation out of my mind. What led to such a shocking consultation and what could I have done differently if I were in the doctor’s position? I think one of the biggest lessons I learned from this incident is that we should never forget the patient in our management of disease conditions no matter how busy our schedule is. It’s only when we realize that our primary role is to treat the patient, not the disease, that we learn to provide empathy and alleviate suffering. Sometimes, kind words can be equally, if not more, important to any medical treatment we offer, especially for patients coming to the end of their lives.
Anonymous. HKUMed MBBS 6
