What about the time –
you know, when it's time to break bad news.
And I think this applies to cases when the
patient is about to expire and pass away.
But I think it also applies to a
patient being told they have cancer
or it could even apply to patients
who have lost control of their diabetes
or can't go running 10 miles
a day like they used to.
I think one of the things I've
learned with bad news is,
really put it in the context of the patient.
You know, terrible tragedies like mortality,
cancer diagnoses, those are easy to understand,
but patients can really take any change to their lifestyle
or a change to their medical condition quite seriously.
So, don't think about the way –
you know, the bad news in the
way you consider bad news,
think of it from the patient's perspective first.
And that will help you break
bad news in a more empathic way.
There are some general rules and some
evidence-based guidelines for breaking bad news.
First, you always want to allow enough time.
I usually do this in an inpatient hospital setting.
And it's really –
well, it’s always busy, but it’s critical just
to set aside enough time that's necessary.
Oftentimes, it’s over the noon hour.
And I create a private
and comfortable environment.
So, I’ll book a conference room and bring
everybody who needs to be in the room in at once.
Now, I've had –
I've led family meetings that have
involved over 30 family members,
in which case we had to actually get –
use one of the small auditoriums
at our medical center to do it,
to accommodate that many people.
One thing that’s really helpful is
to use leaders within the family,
so that way you don't have to
coordinate between 33 different people.
But if you can identify one
to at max three folks
who can determine who needs
to be there at a big family meeting
and get everybody together
for you, that's great!
Also consider other health
professionals whom they know well.
Maybe I'm not the best person
to be talking about the bad news.
I want the nursing staff
there because the families,
the loved ones and the patients
really get to know nursing staff.
Maybe it’s the primary care physician
who can come in over a noon hour sometime.
So that can be really helpful.
Try to make it a team effort because that's important
to be relatable to patients and their loved ones.
Fire a warning shot.
And what that means is let the
patient know I have some bad news for you.
So that way, they're kind of warned
and emotionally ready when something –
when you tell them whatever news it is.
When you do so, be very clear.
Don't beat around the bush.
I'm sorry to tell you this, Mr. Smith, but your cancer
has spread and we think that's going to be fatal.
We believe there is no more treatment
we can offer to cure your cancer,
but we do want to make
you as comfortable as possible
and we will be there to support
you every step of the way.
So that's clear.
I'm not using a lot of jargon talking about
the tumor has now metastasized
into your T12 level spine
and it's also in your ischium.
You want to avoid jargon.
You want to be clear and deliver a message
that the patients can really understand.
It can go fast or slow.
Sometimes patients are already –
they’re usually more ready for bad
news than we give them credit for.
They know what's going on.
But go at their pace.
Allow time for tears.
Allow time for questions.
Emotions may run high,
particularly among family members.
Don't react to that.
Just keep it at a nice basal level.
And always be prepared when
you go into these meetings too
because there might be questions,
why wasn't this tumor diagnosed earlier?
And so, you want to have a little bit of sense of the patient's
history before you go into a family meeting in particular.
Importantly, you always offer hope
at the end of one of these discussions.
And how do you do that?
Because, especially if you’re
talking about a fatal diagnosis,
how do you offer hope?
I gave a little bit of an insight
as to how in that brief example.
Because I talked about,
we are going to make you comfortable,
we are not going to let you suffer,
and we will be there for you
for every step along the way.
So, you always, always end
with a message of hope.
Patients and their caregivers
really appreciate that.
Later in the day,
it’s great to circle back and make sure that –
see how they're doing emotionally,
but also test a little bit for comprehension.
You know, can you tell me about what you
understand about your diagnosis today.
A little bit of teach back.
And then answer any questions they have.
So, it's important to get the
pharmacology right at the end of life.
It's also a critical time for communication.
It's like your final exam
when it comes to communicating with
empathy with patients and their loved ones.
But when you do it and you do it right,
it leads to much better outcomes
where everybody feels a lot better
about something that really
is inevitable for all of us.
Thank you very much.