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INCIDENT REPORT Finding a Good Way to Give Bad News The response to the incident below was written by Annekathryn Goodman, HMS associate professor of obstetrics, gynecology and reproductive biology at Massachusetts General Hospital. Incident: A resident was charged with telling a patient that he had cancer and that an operation would not be indicated. The patient was a Haitian man in his 60s who had metastatic prostate cancer. He was suffering from lower back pain and urinary problems. He was a humble man who did not have a command of English. He did not yet know he had cancer. The resident and a student went into the man's room while he was having breakfast, and the resident asked him if he knew about his situation. He said no, but the student noticed that he looked worried. The resident told the man that he had prostate cancer, which had spread to other parts of his body, and the doctors could not operate. The resident asked if the patient understood. He nodded his head without saying a word. The resident said good-bye and started to walk out. Before leaving, the student noticed that the man had begun to cry. Response: This story opens the doors of our hearts. The three participants--patient, student, and resident (who could be male or female, though for simplicity, I have used the masculine pronoun)--were all changed by this encounter. The patient brings his most precious possession, his body, to the hospital because of illness. He is frightened and, on some level, knows that something is seriously wrong. The resident is told to tell the patient his diagnosis. He dutifully does this; however, he clearly has not been trained in the art of giving bad news. The student as observer records the interaction and sees the psychic pain of the patient. While we can retrospectively criticize the resident, he did the best he could given his level of skill and training. If there is to be any blame for the lack of sensitivity in this encounter, it should be placed on whomever inappropriately delegated this important task to the least experienced member of the team. It is more productive to analyze why these encounters occur and what we can do to better train physicians. Psychic wounding of patients can occur out of emotional ignorance, personal insecurity, or a lack of knowledge about the great social and spiritual resources that are available in most hospitals. There is a tendency for students and residents to assume that their role on the team is not important to the patient. After years as passive observers, students and residents do not realize that their words and actions have tremendous impact on patients. People with life-threatening illnesses hang on every nuance, word, gesture, and facial expression of their medical team. In addition, it is very frightening for health care providers to give bad news. We want to do a good job. We fear rejection from our patients. Giving bad news can be as devastating to the physician as to the patient. It takes experience with caring for very sick patients to realize that most people can accept bad news. This is especially true if the news is delivered with kindness and with the promise that the doctor will not abandon the patient. If we could set the clock back and redo the encounter with this gentleman with metastatic prostate cancer, what would we do differently? The first thing to consider is how to set the environment for the meeting. Given that English is not this patient's primary language, a hospital interpreter should be available. It is important not to use family members to translate serious information. Second, a meeting to discuss the result of the tests with the patient should be scheduled in advance. This allows the patient to be prepared to receive information. The patient should be asked if there are family members that he would like present for the meeting. One should also consider asking the social worker to attend the meeting. Social workers can be very helpful allies in giving emotional support to the patient and family and also aid in setting up resources for when the patient goes home. After news is delivered, it is important for the doctor to sit with the patient and not just walk away. It is very frightening to receive bad news. It is OK to sit in silence with the patient while he absorbs what his doctor says. I also think it is important to offer some kind of intervention. For instance, after saying that surgery would not be effective therapy, the doctor needs to reassure the patient that he plans to work on controlling his pain. The physician can also mention that he plans to consult medical oncology and consider some form of chemotherapy. Patients need to know that the doctor has a plan of treatment, even if it is palliative care and not active cancer therapy. How can physicians learn to give bad news with kindness and with personal strength? We as older doctors need to openly discuss how bad news is given, and we need to role-model for younger physicians. Young physicians and students must have a safe space provided to them to give and receive feedback about the heartbreaking work that doctoring can be.