How doc­tors should give bad news to pa­tients

Pe­di­a­tri­cian shares her ex­pe­ri­ence of get­ting un­wel­come di­ag­no­sis

Richmond Times-Dispatch - - HEALTH - BY MAR­JORIE S. ROSEN­THAL,M.D. © 2020 The New York Times

I know bad news is com­ing my way when my on­col­o­gist walks into the exam room with a nurse. It doesn’t mat­ter that he in­tro­duces her as a new nurse get­ting to know the sys­tem. In my more than six years of see­ing my on­col­o­gist for metastatic colon cancer, he has never come in ac­com­pa­nied. He wants her in the room to learn how to give bad news.

Af­ter 25 years as a pe­di­a­tri­cian, I know the guide­lines. Find a quiet room. Give the news di­rectly. Al­low for si­lences. Of­fer tis­sues and glasses of wa­ter.

Wait for the fam­ily’s ques­tions and an­swer them as fully as pos­si­ble.

I’ve had to tell fam­i­lies that their child has a chronic dis­ease, is gravely ill, has died. Now my on­col­o­gist ro­tates the chair fac­ing the com­puter so it faces me. He sits down, makes eye con­tact, glances at the box of tis­sues by his side.

The nurse stands just be­hind him, shift­ing her weight be­tween her feet. I sit on the exam ta­ble, with two of my friends next to me, hold­ing my hands.

There are new liver le­sions grow­ing, my on­col­o­gist says. For years the le­sions were dor­mant, en­cased in cal­cium. But the cancer cells have burst through their cal­cium bor­ders. They are not yet wreak­ing havoc. My lab­o­ra­tory val­ues and vi­tal signs are nor­mal. But the new liver le­sions mean chemo­ther­apy is no longer work­ing.

I step out of my pa­tient role and into my doc­tor role just long enough to ac­knowl­edge that my doc­tor is very good at giv­ing bad news. He is ask­ing what ques­tions I have. He is al­low­ing for si­lence. Tears are fall­ing from my eyes, and he is silently hand­ing me the box of tis­sues.

The nurse nods when he talks about the next steps. He will look into clin­i­cal tri­als and new med­i­ca­tions. On Mon­day, he will meet with his col­leagues to dis­cuss my case. They will pull up images of my scans and dis­cuss ra­di­a­tion, surgery, im­munother­apy. Pos­si­bil­i­ties. The nurse nods, op­ti­mistic.

I look at the scans on my on­col­o­gist’s com­puter screen. He rolls the mouse to make the images big­ger than life. He touches the light gray ovals of cancer on the CT scan and con­trasts them to the darker gray of the rest of the liver. He points to the bright yel­low sun­burst-shaped spots of cancer on the PET scan — they stand out starkly against the pur­ple-gray color of the rest of the liver. When I was a med­i­cal stu­dent, I thought those images looked like mod­ern art. But not to­day. To­day I know that those gray ovals and yel­low spots are my grow­ing cancer re­act­ing to the con­trast fluid in­fused in my body.

My on­col­o­gist can­cels my chemo­ther­apy for the day. While I wait to fig­ure out the next steps, I will be full of un­cer­tainty and fear of the grow­ing cancer. But not hav­ing chemo means my next few days will not be full of nau­sea, di­ar­rhea and ex­haus­tion. No chemo means I will not need to go home and get un­der the cov­ers.

The day opens up. Hav­ing cancer has taught me about pa­tience and lack of con­trol, and how to spend as much time as I can with those I love. I pro­pose a hike with my friends. They say of course, and we drive the 10 min­utes to Sleep­ing Gi­ant State Park.

One friend chooses a trail I do not know. She says it will wind

He is ask­ing what ques­tions I have. He is al­low­ing for si­lence. Tears are fall­ing from my eyes, and he is silently hand­ing me

the box of tis­sues.

along the river be­fore ris­ing up the hill.

The trail gives us a good view of the trees that fell from the tor­nado a few years ear­lier. Some trees are dead, and oth­ers, whose in­tri­cate root sys­tems have grown side­ways and above the ground, seem to be re­gen­er­at­ing. The day of the tor­nado was dur­ing a non-chemo week. I was driv­ing my older daugh­ter home through what was, in our town, just a bad rain­storm. I was not wor­ried. I had no idea there was a se­ri­ous storm brew­ing nearby.

We rest on a fallen log in a sunny spot. We talk of our chil­dren and part­ners and pol­i­tics and cancer.

Af­ter our hike, we stop at the phar­macy to pick up pass­port pho­tos. Last week, be­fore my on­col­o­gist walked into the exam room with a nurse, my teenage daugh­ters and I had the pho­tos taken be­cause our pass­ports were ex­pir­ing.

This week, I won­der if I will ever leave the coun­try again. I had hoped to have more ad­ven­tures. I am con­fi­dent that my daugh­ters, just on the crest of their adult­hood, will travel widely. At the cash reg­is­ter are ex­tra-large choco­late bars. I buy two.

At din­ner, my daugh­ters are cu­ri­ous about how I had time to make din­ner and why I am eat­ing din­ner with them. They know my typ­i­cal chemo day has me nap­ping all af­ter­noon and into the evening.

I tell my daugh­ters the news. I tell them I am on a chemo hol­i­day be­cause there are new can­cer­ous grow­ing liver le­sions. The big­gest col­lec­tion of cells is just more than a half-inch wide. My daugh­ters spread their thumbs and in­dex fin­gers to es­ti­mate how big that is. It is small, they say.

My daugh­ters re­treat to their rooms for home­work.

I have known for over six years that there would be le­sions that would es­cape the clutches of chemo­ther­apy. I am sad it is now. I had hoped for more time.

But there is no de­nial. I met the nurse who came into the exam room to learn how to give bad news. She, with her freshly pressed scrubs, will be bet­ter pre­pared to give the bad news next time.

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