19 November 2009

How patients face Bad News

Dr Rob wrote yesterday about breaking Bad News to patients.  It's a great post and well worth a read.  I suspect that for Dr Rob, as for most primary care physicians, Bad News is a fairly uncommon part of their daily life.  For ER docs, it's perhaps not an every-day expectation, but in even a moderate-acuity ER it generally is a near-daily part of the job.

I had a shift recently where I was The Raven.  I went from room to room, it seemed, dispensing Bad News.  Not the most fun shift I have had.  "You know that numbness in your hand?  Brain tumor.  Sorry."  "Hey, that vaginal bleeding? Turns out your baby died a couple of weeks ago.  Bummer." "That chest pain you had yesterday went away because you completed your infarction.  You're probably going to need a new heart now.  Just sayin'." "Wow.  Your liver's big. Did you know you had mets?"

The thing that struck me during that shift, as it has so many times before, is how differently people experience and process Bad News.  It's almost like a case-control study, since I have a fairly standard method of dropping the hammer on the poor folks who receive The Badness.  How they respond seems more dependent on the patient-specific factors than on my delivery.  For example:

Option 1: Hysterics.  Common in the young, common with less serious bad news, and also common in certain distinct social/cultural groups.  More common in the families of the afflicted than in the patients themselves.  Can present with simple weeping, but can easily escalate to high drama.  Faux seizures and violence against walls are common elements.  The most distressing thing I have recently seen was a young man harshly mistreating his girlfriend/fiance who was having a miscarriage.  We were all kinda sorry he didn't cross any bright lines so we could have called the cops on him.  Challenging to manage in the short term, but tends to blow over quickly.

Option 2: Paralysis.  Perhaps the most common response.  As Dr. Rob says, "Saying words like “cancer” is like dropping a bomb; people won’t hear much else in the visit after you say that."  So true.  The unexpected "Hey, that's a tumor" on CT scan commonly results in this sort of emotional vapor lock.  It's much worse when there's no action item and when the patient doesn't feel that sick.  Typical physical findings include the fixed thousand-yard stare and monosyllabic responses to direct questions.  For me it's a non-management item, since I'm usually passing the baton to the inpatient team, but I feel bad for these folks.  I feel obligated to try to draw them out of the catalepsy, but in truth, these folks just usually need some time to process.

Option 3: Incomprehension.   A real challenge when it's genuine:
"So it'll just ... grow back again, will it?"  I've heard the equivalent of that many times.  "So they'll just cut out that liver mass then, will they?"  No, it's metastatic.  They can't cut it out.  "Right then, so after they cut it out, I'll be fine."  No, I just told you they can't cut it out.  To be fair, I suspect many cases of supposed incomprehension are just paralysis with a facade of incomprehension.  Denial, if you will.

Option 4: Fatalism.  Reminds me of an Onion story: "Faced with the prospect of a life-threatening disease, the 34-year-old husband and father of three drew a deep breath and made a firm resolution to himself: I am not going to fight this. I am a dead man. On Feb. 20, less than a month after he was first diagnosed, Kunkel died following a brief, cowardly battle with stomach cancer."  This actually seems more common with cardiac or stroke patients.  I tell someone that they are having a heart attack, and they just sort of check out and let events overwhelm them.  I recall one guy heading off the the cath lab, all of 45 years old, telling his wife, "I've had a good run."

Option 5: Stoicism.  Directly proportionate to the degree of familial hysteria, it also presents on its own.  I personally am quite comfortable with the stoics, because I think I identify with them.  A more long-term thinker might worry about their coping skills when the shit ultimately hits the fan and the stoicism runs out.  But in the short term it's a useful mechanism to defer the anxiety and grief than accompanies Bad News, and it's probably the easiest for me to manage.

Option 6: Creepy stoicism.  There are things so awful that the stoic response is glaringly maladaptive.  I remember a dad, informed of his young son's death, who calmly responded that the Good Lord giveth and taketh and are there papers for me to sign?  Wowie.  Sick sick sick.

Option 7: The mature response.  I don't know how to better describe this, but some people have the gift of a capacity to absorb the bad news, allow an appropriate shared emotional reaction, and turn back to me with an "OK, that sucks, what do we do now?" demeanor.  I'm not sure I'll handle it that well when it's my turn. I hate this because it's an article of faith in the ER that the nicest people always have the worst outcomes, and these are the folks that I tend to really like, personally.

I'm sure I've missed a few variations, and the possible combinations of the types are near-infinite.  As a student of human nature I am fascinated by the differences and commonalities in the responses.  I feel sympathetic grief for these folks, the few among the hordes of worried well congesting the ED who bear real life-changing illness.  Generally I don't get to do much to help them.  I'm the perennial bad guy -- I drop the bomb and then shuffle them off to someone else to get better -- which is a pity because I'd really like to have a positive contribution to their care.  I console myself that the bearing of the Bad News is an important job in itself, that well-done it can position patients to accept and move forward, whereas poorly-managed it can be highly traumatic.  So by being tactful, careful, and supportive in my presentation, the diagnosis can be the first step in the therapy. 

But it's still never fun.


  1. Me: "Well, I think you have the flu."

    Patient: "At least it's not the SWINE flu, right."

    Me: "Given the current epidemiology, it most likely is."

    Blank stare, "Epidemi what?"

    Me: "Yes, you have the swine flu."

    Queue the hysteric response.

  2. I think Optiions 5 & 7 were how I greated Obama's election.

  3. "Generally I don't get to do much to help them. I'm the perennial bad guy -- I drop the bomb and then shuffle them off to someone else to get better -- which is a pity because I'd really like to have a positive contribution to their care."

    That really sucks. When my first wife died in the Big Beige Hospital on Colby after minor surgery I actually went back a few days later to thank everyone that I knew had cared for her while she was there. I know I missed some due to the nature of hospital work, but did my best. The reactions I got ranged from tears to "Who?";but were mostly positive. I gave the small stuffed animal she had in pre- and post-op to her surgical nurse and later saw it on her bicycle on STP. Damn, it's hard to ride a bike with tears flowing...

  4. I'm right with you on judging the miscarriage boyfriend.

    All these others, if you think their response is lame or whatnot, best of luck not peeing your pants and crying for your momma if/when it happens to you (or someone important to you). Worse, in the aftermath of reacting like a ninny, the patient gets to wallow *forever* in the firm knowledge that what they're "made of" isn't very solid stuff. Or in the aftermath of handling it well, the patient finds out they're a million times stronger than they had any idea. On average: surprising as all hell.

    You'll likely be denied the experience, since you've watched it happen a million times and you'd no more fall to pieces than you'd pick your nose in public. ER docs might be the least surprise-able species, regardless.

  5. Interesting post.

    When the doc told me that I probably had breast cancer, I was kinda floating - not quite there - I wonder if I had the vapid stare you describe. I also took it very well, because in my own silly mind and I think because of all the rah-rah "awareness" press, I thought breast cancer was curable and not a big deal.

    It only hit home when the surgeon said I had to have a mastectomy and probably a double and an ooperectomy. "You want to cut off my boob - and I have no choice - WHAT????"

    I often imagine my response if and when my docs discover mets. I think I'll move right into hysteria and perhaps disbelief.

    The best response, by the way, I got from any of my friends, was a simple, heartfelt "I'm sorry." My guess is that it works for docs too.


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