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Breaking bad news is never easy. And comes in many guises. It’s not just about death or diagnosing a fatal disease. I gradually realised that many things qualify as ‘bad news’ to others which to me seemed relatively minor. As a student  I hadn’t understood the likely impact of my words or the preconceived ideas patients would have which meant they would interpret my breezy announcement about their condition in a way I did not predict. I would say “Mr Jones it looks like you have a condition called diverticulitis which has been causing this bleeding from your bottom” and I would expect him to be as relieved as me that it wasn’t cancer. But sometimes Mr Jones would appear to be as devastated as if I had told him he had a month to live. Because of course I stupidly didn’t realise he would have no idea what a diagnosis of diverticulitis would actually mean.  Because I hadn’t told him.

So I quickly learnt that what seemed to work for me was to be explicit upfront about the diagnosis NOT being cancer. It surprised me how many patients default to imagining they do have cancer or a serious fatal illness whatever their symptoms. Not everyone obviously, but lots of people. So I would always ask people what they thought it might be so I could be explicit and clear in my reassurance if we were able to exclude that particular problem.  It made it easier for me too as it somehow gave it a platform of being not the worst news even if it wasn’t good news. A perspective of relativity perhaps.
We had classes on giving people terminal diagnoses. What to tell them. How to tell them. How to listen. How to ask. How to remember the patient when all the family are insisting on a particular course of action.  It would often be more stressful battling with the family to treat their loved one as an intelligent adult than talking to the patient themselves. They often seemed to insist that their parent or partner would not be able to take it if they were told their diagnosis. But I had no right to withhold that information if the patient was of sound mind. And I found that patients do tend to give you pretty clear signs how much they want to know if you ask them.

As a student I had been with doctors when they were delivering bad news to patients, but there comes a time when you are the one to have to do it, not be the sympathetic bystander. Unlike nowadays, we did not have roleplays to practice our technique and responses but if I am honest I am not sure how useful roleplays are unless they use real patients who have been through it. Actors, no matter how good, are not real patients and come with their own  ideas of how they would react which is not necessarily the same as seeing it in real life.

But anyway, I’d seen it in real life before I did my first. In fact, unlike the usual medical adage of see one, do one, teach one I had seen it a few times before I was left to do it myself. I had really enjoyed my stint on the Oncology ward as I blogged here, and had seen an inspirational Consultant talk to his patients about death and dying. The best possible training. Except that this wasn’t really the same scenario…

I think it only fell to me this particular time because it was at the weekend and an emergency so the more senior doctor who had been with me trying to save the patient’s life had been called away to another patient. And the living take priority. So I was left to tell the parents and boyfriend of a seventeen year old girl that we had been unable to save her from the anaphylactic reaction she had had. Because they needed to know. They had a right to know. We couldn’t let them just wait until my more senior colleague was finished. That could have been hours. They would already have been waiting for over an hour wondering how she was doing since she’d been brought in semi-conscious. And so with pounding heart I went to find them in a small side room in Casualty.

A nurse came with me and we walked in to the room. They all instinctively stood up and looked at me expectantly.  And then the boyfriend started crying when he looked at my face. It was so hard. I had been the one who had taken the history from him to find out what had happened as by the time she arrived she was losing consciousness so couldn’t speak. Her parents didn’t arrive until later. So I already had a relationship with him. And I expect he saw it in my eyes that it was the worst news possible.

I don’t remember where the nurse was, but we all sat down. I drew my chair up so close my knees were touching the mother’s. And then I told them. I tried not to use euphemisms and said that we had done everything we could but she had died. I remember thinking I shouldn’t say things like “She’s gone” in case they might think I meant she’d gone to another hospital or just out of the building. And the father appeared stoic and supported his wife who looked shell shocked. I asked them if they had any questions and did my best to answer them. But it is often too early to have questions when you have been hit by the ten ton truck of sudden death. So in fact there were few, mostly about what she would or wouldn’t have been aware of. And whether she would have been in pain.

And they were very gracious and grateful and thanked me for all our efforts. And I felt terrible. And their niceness made me well up even more. I was trying to stay professional but I could feel the tears. The throat closing in. I wanted to leave before I crumbled completely but felt I couldn’t just get up and go abruptly. We sat and I held the mother’s hands. “I’m really sorry,” I said as I got up. The father shook my hand. The boyfriend was still as a statue looking at the floor. I touched his shoulder as I left the room. The nurse stayed to talk to them about what happens next.

And I really was sorry. This wasn’t just a trite saying. Sorry for their loss of course, But the overwhelming feeling was guilt that we had failed. Sorry we hadn’t been able to save her. And I went over and over it in my mind. Could we have done something differently? Had I done something wrong?  We are trained to save lives and make things better and it is hard to come to terms with failure, even if you have done everything possible. It was awful.

They do say relatives often remember this kind of conversation with incredible accuracy and replay it in their minds. I hope to fuck that I didn’t make things any worse for them than it already was by the way I handled it. But I’ll never know.

When people talk about stress in their work I am minded to shout that they’ve got no fucking idea what work related stress is. But I don’t of course.

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