Breaking bad news is a skill; it’s not something that one is born great at, but takes learning and deliberate practice to improve. Unfortunately, bad news is common in healthcare, while we might wish that everyone gets better, it is the nature of the human condition that eventually we don’t.
One unplanned admission—opposed to a planned or elective admission—in older adults is often the harbinger of more to come, and can portend decline and regrettably death1. Hip fractures are commonly cited to carry a 1 year mortality in the region of 20–30%2, something that’s not always communicated well. Suffice it to say that within months of starting work as a doctor, there will have been plenty of opportunities to practice giving bad news.
When starting out, fresh in the face of the newly upon us pandemic, I found it difficult to separate myself from the information it was my job to impart. Negative reactions from patients and relatives felt like negative evaluations on me and my suitability as a doctor. No one is ever going to be relieved or joyous at a new cancer diagnosis or at the knowledge a relative is terminally ill, but I’m ashamed to admit that I occasionally felt the natural grief or sadness in response to the news was criticism of myself and my skills, as though a better doctor would have everyone smiling and contented at the end.
While I am aware that this may come across as ego, trying situate myself as the centre of things, in hindsight I believe it stemmed from a sense of responsibility, not just for the manner of the discussion, but for the content of the results. As absurd as this sounds in retrospect, I have never given someone cancer, I think a sense of potentially crushing responsibility is a common experience for many newly qualified doctors. Going from the training wheels world of medical school, overnight they are stripped away and suddenly you have your own patients that it is your job to look after.
However, for the sake of ones patients and ones own sanity, there needs to be at least some level of distance. It is possible to inform with empathy and compassion, yet not feel like the direct cause of someone’s suffering. Aside from leading to ones own personal distress, one needs to be mindful of the effect this has on how exactly you break bad news.
In April of 2020 one of my patients was an elderly gentleman with COVID, this was pre-vaccine, pre-dexamethasone, and pre-antiviral. Although he had been admitted a few days ago, I had not met him before, and unfortunately he’d been deteriorating. He was in his 90s, had a clear escalation plan, and DNAR filed at the front of his notes, it wasn’t murky which direction he was heading, and I had the job of updating his son, who lived a couple of hours away.
I think I can remember stumbling down the traditional pathway of saying that things weren’t looking good, that his father had continued to deteriorate, and that there wasn’t any headroom if this should continue. I can vividly remember it coming down to his son asking “shall I leave now, or come up in the morning?” To be honest, I can’t recall how exactly I responded, but I think I probably didn’t say the obvious fact, that his father was dying, if not this evening, then the day after, or in the few days after, and that he should come to have his last moments with his father.
In defence of my first year doctor self, it is often quite difficult to predict when exactly someone will die. Sometimes it is very obvious and rapid, sometimes it is inevitable, but drawn out over days or weeks. To some extent, there’s a degree of professional pride in not wanting to be the proverbial boy who cried wolf about a relative’s imminent passing, and not wanting to put a family through unneeded pain. You occasionally run into families who have become understandably somewhat jaded, having been called in multiple times to bear witness to their supposedly dying relative.
After leaving, I can remember dwelling on what his son had decided, and what would greet me that following morning. It turned that he had left about an hour after our phone call, but that it hadn’t been soon enough, his father had died on his journey to us.
I do question whether the strength of my words in that conversation cost that man the chance to see his father alive for the last time. Rationally, I could add up the time it would take for someone to make their decision, gather up their things, and calculate the expected travel time, and in the end there probably wouldn’t have been that much in it. Regardless, there were lessons to be learned in how I conducted myself that I have sought not to repeat.
First, one needs to be mindful of the euphemisms we jump to, whether through awkwardness, or to attempt to soften the blow. Phrases like “isn’t doing very well”, “hasn’t improved” or “continued to decline” are potentially fine as part of a conversation, but they don’t express gravity, especially to people who might not know their significance. Kathryn Mannix has written about people struggling with the ‘D-words’, such as dead and dying, and how they’re sometimes difficult for us to say when we need to.
Secondly, where possible try to establish a relationship with the patient and their family prior to these conversations. It is not always possible, such as out of hours or in an emergency, but having a sole point of contact is useful, and that applies to doctors as well as patients' relatives.
Thirdly, discuss early and often. It is rare for someone to suddenly die several days into their admission with no warning, although admittedly it can happen. Far more commonly, the prognosis is grave from the outset, but that this is not always communicated early enough.
Finally, don’t try to predict how people are going to react, give them their time to process what you’ve said, and ideally follow up later to check understanding and make sure there haven’t been any misunderstandings. You’ll often here it said by patients that they can’t remember anything after the word ‘cancer’ for example.
Giving someone the worst news in their life to date is never going to be a joyous occasion, but doing it appropriately and sensitively can let someone take the most out of what they have left. As doctors and clinicians it’s possible to have a tremendously positive impact with a few carefully chosen words.
Quinn KL, Stall NM, Yao Z, et al. The risk of death within 5 years of first hospital admission in older adults. CMAJ. 2019;191(50):E1369-E1377. doi:10.1503/cmaj.190770 ↩︎
Downey C, Kelly M, Quinlan JF. Changing trends in the mortality rate at 1-year post hip fracture - a systematic review. World J Orthop. 2019;10(3):166-175. Published 2019 Mar 18. doi:10.5312/wjo.v10.i3.166 ↩︎