Giving the bad news

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We've had more than enough bad news lately about the economy, loss of jobs, fraud in the marketplace, and our various wars, so maybe talking about how to give bad news seems timely. Now CNN.com has published an article about the problems that law enforcement officers experience when it's their job to give the bad news to relatives about murder victims and other tragedies. Giving the bad news is hard on the police. Some do it well; others don't. But giving the ultimate bad news is necessary, no matter how hard we stuggle to do it.

Most of us have to communicate bad news to suffering people at some time in our lives, whether it's the type that police have to announce, the type that financial advisors have to give clients who have just lost their life savings in a stockmarket dive, or the type that physicians sadly have to give their patients. No bad news giving is easy.

A few years ago my wife, Jana Staton, and I carried out an ethnographic study of terminally ill patients and their caregivers in order to learn some ways to improve that difficult time of life. Among other things, we wanted to find out what was going well for them and what wasn't. We discovered a lot about how the patients felt their pain was being managed, what activities gave them some small pleasure, their satisfaction with their medical help, the support (of lack of it) that they were getting from their community, their regrets, how they were meeting their ultimate death, and many other things.

Our study was part of a larger research project called the Missoula Demonstration Project and, as far as I can tell, ours was the only part of that study that appeared as a book. We published our research under the title, A Few Months to Live (Georgetown U Press, 2001). Our data came from a sample of the Missoula population that was, in that year, officially designated by their doctors as terminally ill. We visited them (not interviewed, for we let them control the topics) in their homes about once a week after their doctors gave them the bad news up until the week they died, focusing our tape-recorded visits on what both the patients and their care-givers wanted to talk about.

Although we weren't present when their doctors told them they were terminal, the patients related this information willingly and, we believed, accurately. Perhaps oncologists have developed their own communicative strategies to give the bad news, because most of the patients who were capable of understanding it had good things to say about how they were told they were about their forthcoming deaths. Those who agreed to let hospice help them in their last months of life had nothing but praise for how their hospice nurses were preparing them for their ends.

A younger very intelligent cancer victim told us that his doctor used crisp medical terms to describe his terminal status: "The doctor told me that my body would not continue to respond to chemotherapy … it would sooner, more than later, go to strictly pain medication, palliative treatment, and that my immune system would be so compromised that infection would set in and blood sepsis would set in and they would not be able to do anything and my body parts would just start shutting down. And he said at that point we'll just make sure that your pain medication is adequate and we'll make you as comfortable as possible, but I don't see really going beyond the summer…I think we can get you through the summer. He will tell it as it is…but he's as gentle as he can be."

An older emphysema patient reported that her doctor gave her the bad news as a gently posed question: "Is it time for hospice?" The daughter of a patient with congestive heart failure told us much the same thing, only her doctor was more authoritative: "He declared mother hospice."

A bone cancer patient who had positive attitudes about everything told us that her doctor gave her the bad news more indirectly and positively, telling her: "You'd be good for the people at Hospice House."

Another emphysema patient's doctor was more direct: "It's time to get hospice care." He couldn't recall the doctor's exact words but he considered this a professional recommendation that he couldn't refuse.

An younger ovarian cancer patient was too upset to remember that it was anything but "a blur," but her husband translated the doctor's information to her in clearer terms: "It's terminal. We can't give it a time…it doesn't look good. Your chances of recovering are slim."

Not all of the patients in our study were clear about how they got the bad news, or if they ever got it at all. One with considerable mental deterioration did not believe she was ill even to the very end saying, "He wanted to put me in Hospice House…I'm not ready yet." Another vehemently denied she had ever been told, although her caregiver, her daughter, understood very well what the doctor had tried to communicate to her mother.

Language offers many ways to say things. We can be direct or indirect. We can be blunt or tactful. We can prepare patients well in advance or drop it on them all at once. We can give an opinion or ask for one. We can suggest or recommend. And we can highlight what few positives remain, saying things like, "I think we can get you through the summer" or "you'd be good for the people at Hospice House."

Giving the bad news is difficult, no matter which speech act we use. We can be thankful for those who do it well.



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