My stomach sunk. The results of the biopsy were back and it was not good. I had met Ms. Jones eight days ago when she was admitted for a pneumonia that antibiotics couldn’t seem to shake. Once hospitalized, we’d brought out the big guns and she had been clinically improving on that well-loved duo of vanc and zosyn. (Med students take note: vanc/zosyn is almost always an acceptable answer when pimped about which antibiotics to start – they may be overkill, but you’re unlikely to be wrong.) Despite her improvement, things had not been adding up – we kept putting 2 and 2 together and getting 6. A young woman in her late 30s, she had no good reason to have this month-long pneumonia and her chest x-ray looked, in a word, terrible. Even I as an intern could see that what had been a right middle lobe infection when she first presented a month ago was now also in her upper lobes and – oddly – her left lung was looking increasingly cloudy.
Puzzled, we had ordered a CT. And that’s when we saw them – large masses on each side of her lungs invading into her bronchi. As a team, we held out hope that it could still be something other than what we all feared. Maybe it was a weird infection? She had had some unusual skin infections in the past. She was getting better with the antibiotics, after all. She had no family history of cancer and she was a life-long never smoker. “I didn’t even try it in high school,” she told me with a slight laugh, “I wasn’t much of a rebel.” Besides, she was just very likeable. As an intern, you learn that not all your patients are easy to get along with or appreciative of your care, but Ms. Jones was both and, in the afternoon when I would drop by her room to check in, we would end up spending a few minutes talking about her kids and her life.But those masses had earned her a biopsy, and we had all waited impatiently for the pathology report. Thus when those results finally arrived and revealed the words squamous cell carcinoma I cursed silently to myself. “The results are back,” I said, turning to my senior sitting at the computer next to me.She glanced over at the screen, “Oh boy. Well, let’s go tell her.”“Us?” For some reason, I had assumed our attending would be the one to tell her, with his appropriate grey-haired gravitas and decades of experience to rely on.
But as I stood, slipping on my white coat with a bit more hesitancy than usual, my senior turned and said, “You’ll tell her.” Probably seeing my face, she added, “I’ll be there for back-up.”
Climbing the stairs, my mind raced, trying to pull together words into phrases, phrases into sentences, sentences into paragraphs that would convey this terrible news and make it, magically, less terrible. Somewhere in my brain, I was vaguely searching for a mnemonic – didn’t they teach us something for delivering bad news? Isn’t there a mnemonic for everything? But then we were in the room and all I could think was sit down. I must be sitting down. This was not news you give standing, poised to run as soon as the words escape your lips. This was sit-down-and-make-eye-contact news.
By some small grace, Ms. Jones’ sister was there. She had not been there before and, as I introduced myself, I was thankful for her presence, with vague memories that bad news ought not be delivered to the patient alone if at all possible. I started to smile reflexively as I introduced myself, then realized the smile was out of place and rearranged my face to approximate something that I hoped approached both solemnity and compassion. While I was glad she was here, I was not sure what to do with the sister, how she influenced the telling. What does she know? And, looking around for a place to sit, I wondered, how is it possible this room has no extra chairs in it?
With grace, my senior slipped a chair into the room, gesturing for me to sit down, and said, “Does your sister know much about your hospital course? Would you like us to fill her in?”
Ms. Jones nodded, “Please.”
With that, I was off, explaining the course of the hospital stay to this point, painting for her our concerns, the progress, the tests. Then my focus shifted back to Ms. Jones. “The pathology results that we were waiting for came back just now. I’m afraid it’s cancer.” While her sister let out a small gasp, her expression is completely flat. Later, my senior, who was perched unobtrusively in the back of the room, would say this was when I should have stopped, have waited, giving the news its own space. Instead, there was the briefest moment of silence and I felt obligated to fill it, to reassure by offering some semblance of control over the situation. “We have a plan, though. Right now, I’m going to go call the oncology team. They’ll help us figure out what the best treatment plan is, whether that’s chemo or surgery or radiation. . .” I driveled on, offering far too much information. At some point, I did stop talking when I could think of no more words and found myself repeating the same phrases. “Do you have any questions?”
She shook her head. Still there was the flat expression, but tears had begun to stream from the corners of her eyes. I offered her the nearby box of tissues. “I’m really sorry, Catherine.” Her first name slipped out. It seemed the only right thing to say. She nodded, taking a tissue. We were all quiet for a long moment.
“Is there anyone we can call for you?” my senior asked.
Catherine shakes her head.
“We’ll be back later to check in and answer any more questions,” my senior adds. We leave, silently descending the stairs back to the workroom. The day goes on, like any other but different. Because this is the day I told someone they have cancer.
* * *
There actually are a few different mnemonics for breaking bad news (is there any bit of medical knowledge that has not worked its way into a mnemonic?). While having a mnemonic for something as profoundly human as relaying significant news may seem contrived, it can provide a helpful framework for what can be an emotionally charged situation. Although there are a number of them out there, SPIKES seems to be one of the most popular.
S – Setting up the conversation. This includes mental rehearsal of how you plan to deliver the news as well as the physical staging of the conversation itself. In my case, my rehearsal was on the way to the room – both I and the patient might have benefited from more time for me to think through this. If it’s your first time, consider running what you are going to say by someone more experienced. Regarding physical setting of the conversation, we hit the important features – there was privacy, a relative was present, we were not interrupted, and I did manage to sit down.
P – Assessing the patient’s Perception. What does the patient know about what is going on? In Ms. Jones’s case, we had had a daily discussion about the pending tests, so this did not occur explicitly during our conversation. However, her sister was largely unaware of the chain of events, so it was important to fill her in in order that she might better appreciate the news that was to follow.
I – Obtaining the patient’s Invitation. Different patients want different levels of information about their diagnoses. While some may want all the details, others may prefer a broad sketch. It is important to understand this and respect the patient’s wishes.
K – Giving Knowledge and information to the patient. For actually delivering the news, a warning shot may be helpful, such as “I have some bad news to tell you.” Be sure to use terms the patient will understand. I made a conscious decision to say “cancer” rather than squamous cell carcinoma, for example. Knowledge should also be doled out in digestible portions. I definitely erred here, launching from diagnosis directly into next steps. One should take the time to pause, checking the patient has understood. More details can often be saved for later, after the news has had a chance to sink in.
E – It’s all about the Emotions and Empathy. Studies show this can be the hardest part of breaking the news. It means sitting with the patient, reaching out, and recognizing the turmoil of emotions they are going through. Make sure there are tissues.
S – Strategy and summary. Knowing that there is a plan for next steps can help alleviate some of the anxiety and uncertainty that comes with serious medical news. At this stage, it’s important that the patient is actually ready for this information. While I launched into our plan right away, it may have been better to come back later in the afternoon to talk about what was coming next, giving the patient and her sister some time to absorb the life-altering news of those pathology results.
Breaking bad news is an unavoidable and important part of our role as physicians. Although it can be daunting, particularly the first time, done well it can ease suffering and bring us closer to our patients. Dr. Robert Buckman, who literally wrote the book on the subject (How to Break Bad News: A Guide fror Health Care Professionals) may have put it best when he remarked about breaking bad news, “If we do it badly, the patients or family members may never forgive us; if we do it well, they may never forget us.”
References
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP (2000): SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. The oncologist. 5:302-311.
Megan Riddle, MS MD Ph.D., is board certified in both adult psychiatry and consult liaison psychiatry. She attended Western Washington University and received a Bachelor of Arts in Spanish with minors in Latin and English before deciding she wanted to pursue a career in medicine and research. She received a Master’s in Biology at Western Washington University with an emphasis in genetics and then went to Weill Cornell Medical College where she earned a medical degree as well as a PhD in neuroscience. She completed her residency training in psychiatry at the University of Washington, where she was chief resident, before completing a fellowship in consult liaison psychiatry, also at the University of Washington. She is currently a Courtesy Clinical Instructor with the University of Washington Department of Psychiatry and Behavioral Sciences and enjoys teaching and supervising residents.