As a brand new intern, I had this art form thrust on me. It was during my third month of my intern year of my family practice residency that I first met this patient who would be the first to receive my version of bad news. The patient was in his 20s and suffering from advanced stages of AIDS. This was back in the day when we were just starting to use combination therapy to treat HIV infections. This man was admitted to the hospital with headaches and some other neurologic symptoms (which I do not recall more than a decade and a half later). The MRI came back and the radiologist reported a CNS lymphoma in an inoperable location. And at his advanced stage of AIDS, he was not a surgical candidate anyway.
The case was discussed with his attending physician, our chief resident, and myself. The attending dumped the actual task of informing the patient of his diagnosis and dire prognosis. And being the chief resident, he then tasked this job to the scut monkey on the internal medicine rotation: me. He did not offer to go with me to the patient’s bedside or give me any words of advice. Basically, he ordered me to do it, and as any good intern scut monkey would do, I obeyed.
I went to the medical library and researched his condition before anything else. There was not much information in the literature. I prayed and then walked up the stairs to push the deed further away than if I had taken the elevator. My hands were shaking and I was sweating. I walked into his hospital room and there he lied in bed with an NG feeding tube in place. I sat down in the chair next to his bed and looked him in the eye. I told him the MRI results and that it did not look good. I told him there was no treatment at the present time. I asked him if he had questions, but he had none. I think he had been suffering so much that he just didn’t care any longer. I mentally willed him to ask any questions and reach for any light of hope. But, he did not. He accepted it quietly, as if it was exactly what he expected. And my hope was lost. I knew his fate was then sealed and he would soon die. I walked out of his hospital room, and once no one could see me, I ran up to the call room and cried and cried.
“…we need to answer all the questions they have and to admit when we don’t know. When we don’t know, we need to reassure the patient that we will help them find the answers.”
I learned many things from this patient. Although I forgot his name, I will never forget the look in his eyes when I gave him the bad news. The most important thing is that as a doctor, it is not all about curing patients and saving lives. Many times, we are called to be the bearer of bad news, and the way we do it is just as important as saving a patient’s life.
Bad news should never be given by the most inexperienced person on the medical team. A patient suffering needs the most expert one to deliver the news and be available to answer their questions. We need to be empathetic when we tell the patient that they have a bad disease or that there is nothing left to do. I try to put myself in their position and deliver the news as I would want to hear it.
We need to understand that we may have just shocked the patient and that they are too overwhelmed to ask questions. We need to give them resources to get answers after their visit is over and make it easy to get back in to see us to address their concerns.
Also, we need to present all the options to a patient. Even though we may think a procedure is too risky for a given patient, we still need to tell them about it and let them decide; it is their life. And we need to answer all the questions they have and to admit when we don’t know. When we don’t know, we need to reassure the patient that we will help them find the answers.
Patients are scared when they come to the doctor. We need to remember they are in an insecure place. In my medical training, I never received any training on how to tell the patient bad news. The art of it has evolved over years of practice. This is perhaps one of the hardest jobs a doctor does. Do you think we are doing a good enough job or do we have to do better?
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Dr. Linda Girgis MD, FAAFP, is a family physician in South River, New Jersey. She holds board certification from the American Board of Family Medicine and is affiliated with St. Peter’s University Hospital and Raritan Bay Hospital. Dr. Girgis earned her medical degree from St. George’s University School of Medicine. She completed her internship and residency at Sacred Heart Hospital, through Temple University and she was recognized as intern of the year. Over the course of her practice, Dr. Girgis has continued to earn awards and recognition from her peers and a variety of industry bodies, including: Patients’ Choice Award, 2011-2012, Compassionate Doctor Recognition, 2011-2012. Dr. Girgis’ primary goal as a physician remains ensuring that each of her patients receives the highest available standard of medical care.