Family Webicine: Giving Bad or Unexpected News

I have been fortunate in my medical career and type of practice settings that I have worked, that giving "bad news" is a rare event. During the course of a typical week, I inform patients of abnormal laboratory tests, or x-ray/imaging findings. Most of these abnormalities are expected and correctable by various treatments, or even "Tincture of Time."

When I order a pregnancy test on a teenager, it is for a reason. They may have been having unprotected sex and are having symptoms of pregnancy, such as a missed period. When I inform them of the results, they have already sort-of prepared themselves. Sometimes, I will simply ask, "How will you react if I tell you that you are pregnant today?" Knowing how they might react, will prepare ME on how to deliver the final news.

Many teenagers play Russian roulette with sex. They secretly wonder if they can actually get pregnant. They are practicing suboptimal forms of birth control, or none at all. Many will be pleased when I tell them they are pregnant; some will "freak out". Both will need some extensive counseling, of course.

Several years ago, I was doing an annual exam on a dear patient of mine. She was in her early 40's and had not had regular periods for years. Thinking she was menopausal, she did not really see the need for birth control.

"Any chance you could be pregnant?" I asked.

"Absolutely not," she responded, as I was palpating a suspiciously-enlarged uterus.

Of course, she was pregnant, and that "surprise baby" was Katie - a beautiful little girl, the love of their lives, and now, a beautiful young woman. This was unexpected news, but not "bad news".

I love giving good news. Who wouldn't? Telling someone that has been trying to get pregnant for years that they were successful; or telling someone who fears their skin lesion is a melanoma that it is benign is all great news. The patient is ecstatic. I feel good. It is a win-win situation. However, life and medicine is not always an endless stream of good news.

No medical provider wants to give a patient bad news, but that is part of our job. If you read my recent blog post about my friend who was diagnosed with a brain tumor last week, you will realize that these types of events are unbelievably frightening to the patient and their families/friends. You pace about and pray for "good news". You stare at the clock waiting for the doctor to come out and reassure you that everything is fine. The tension is thick enough to be cut by a knife.

My friend was five hours into his surgery. Finally, the surgeon came out into the crowded waiting room where the family had gathered. His face was not unlike a jury returning a guilty verdict. Pulses raced. Tears flowed.

In a subdued voice, almost too quiet to be heard, he gave his brief report. "He had a glioma - brain cancer. I was able to remove all of it. I sent the specimen off to pathology for a final report. Your husband is in the recovery room. Do you have any questions?" The only response came from my wife: "When can his wife see him?"

Everyone sat stunned. This was not the news we wanted to hear. Yes, everyone was pleased that the surgery was over and he was in the recovery room, but.....cancer! It is really difficult to hear anything, not even words of encouragement if they were offered, after hearing this dreaded word.

The family decided that it would be best that my friend hear this news from the doctor himself. He went back toward the recovery room.

Later that evening, it was evident that the doctor did NOT tell my friend he had cancer. Perhaps he wanted to wait until morning, after the effects of the anesthesia wore off, to tell him. That made sense.

The next morning, he made his rounds. My friend's wife was at this side. He inquired about how he was feeling, looked at the surgical site, and left after a few minutes. He did not sit down, nor did he discuss the cancer. He did not mention anything about meeting with the oncologist. Nothing.

The following morning, two days after brain surgery, my friend was to be discharged. I was a bit shocked, remembering the days when we would routinely admit men overnight for a vasectomy. The doctor came in and told him to make an appointment in his office for two weeks for a follow-up. Again, there was absolutely no discussion; no mention of his diagnosis.

"I guess I will have to wait two weeks to know if I have cancer."

My friend's wife called in a panic. "The doctor didn't tell him! What should we do? Can you tell him for me? I can't do it."

We were flabbergasted. How could the doctor NOT have told him? Did he forget? Did he think when he told the entire family, that he told the patient, too? Did he tell my friend, who just had brain surgery and was still under the after-effects of anesthesia, and he just forgot? Was he waiting for the final pathology report? Regardless of the reason, my friend needed to know what we already knew. We agreed to tell him.

So, one hour after he came home; sitting at the dining room table where we have shared so many meals and laughs, we told our friend that his brain tumor was, indeed, a cancer.

At first, he sat there in stunned disbelief. Then, he cried. Then, we cried. After a few minutes, our friend was "back". He thanked us for being there for him. He needed time to reflect on the news that was just delivered. He looked understandably tired and frightened.

I had written him a letter while he was having surgery. I read it to him. I will not disclose the content of that letter; it is much too personal. I can tell you that fighting cancer is not an individual battle, but a war - a war that intimately involves all of us. His cancer is a war that we plan on winning.

Now...with the help of God and the miracles of modern medicine, we can plan start those battle plans.

At about 9 PM last night, my friend called to thank us again. He sounded a bit better; more optimistic. Now that he knows his enemy - the cancer - he is ready to join the fight, too.

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Labels: friends, glioma, prostate cancer