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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A Bad Week for Health, My Friends

The older you become, the more likely you will have to deal with health problems, not only your own, but those of your close friends and relatives.

Last year, it was a friend's wife with lymphoma and my sister-in-law with breast cancer. This week, one of my best friends was diagnosed with a particularly aggressive form of prostate cancer. And, yesterday, one of our closest friends was rushed to the hospital when he could no longer speak. Later in the ER, a CT revealed the cause. He had a brain tumor.

Prostate Cancer
Bob has been my friend since college. We met in line since our school felt it necessary that everyone stand in alphabetical order for various functions. Both of our last names began with "M". We were even assigned dorm rooms in alphabetical order, so he lived two doors down the hall. His major was music, and he could really blow the saxophone, plus play the piano and sing. It didn't take us long to join forces with his roommate Danny (now a Baptist minister in the Midwest) before we had a singing trio - the "A-Courtians". The name originated from the fact that we lived in a dorm called A-Court. For the next several years, the A-Courtians would sing for assemblies and a few gigs for the Office of Admissions.

We were both from Pennsylvania and now, over thirty years later, we both live in California. Of course, I pursued a medical career; Bob used his music background to prepare him for a very successful career owning a pump company. After years of losing touch living our separate lives, we found each other's friendship again. We only get together one or two times per year. That is about all my splitting sides can take, since it is a non-stop laugh fest.

Bob's doctor has been monitoring his PSA levels - an indicator of troublesome prostate activity - for a few years. Sometimes the level was elevated; other times, it would go back in the normal range. It was never at the point where his doctor felt further investigation was needed; until recently, that is. His doctor decided it would be a good idea to do a prostate biopsy, in the office, without any anesthesia. This, of course, would never be something that I would agree to. I am personally at the point where I want anesthesia for a hair cut. Bob agreed to this transrectal procedure, telling me it was the most painful thing he has ever experienced - even worse than the time I hit him in the head with an entire sheet of plywood. A complication quickly developed when the surgeon hit a bleeder - an artery. Bob was rushed from his urologist's office to the hospital, losing about three pints of blood in the process. Having cheated death, Bob felt that he deserved to have the biopsy be negative for cancer. Unfortunately, it was not. Although I do not know the details of my friend's case, Bob tells me that it is a particularly aggressive type.

Aggressive types of cancer require aggressive treatments in my opinion. I insisted that he contact the best oncologist in the area. He was particularly fond of the oncologist that took care of his life-partner's lung cancer several years ago. I told him to make that call. Cancer treatment has made leaps and bounds over the years, and newer, more effective therapies orchestrate actual cures, not just palliative treatments. In the experienced hands of a good oncologist, I expect to be laughing and singing with my friend for decades to come.

Brain Tumor
It started with a phone call from George's wife.

"I think George had a stroke. I gave him three baby aspirins. Should I take him to the hospital?"

"Get off of the phone NOW. Call 911."

The paramedics arrived promptly and the stroke team at the ER was waiting for him. Prompt anti-clot treatment is critical; minutes or even seconds can determine outcome. However, George was not having a stroke.

George is a retired professor of anthropology. He speaks about four languages and has traveled and lived and lectured in many parts of the world, from Iceland to Pakistan. As a connoisseur of all foods ethnic, he was preparing a chicken dish for a lunch. He came up to his wife and started to talk. Instead of the usual rhetoric of a learned scholar, what came out of his mouth was gibberish. George thought he was communicating, but the words were not words at all - they were not words in any of his four languages either. They were aphasic words from a damaged brain.

A CT scan revealed the source of George's sudden loss of speech, and subsequent seizures. Silently, a tumor had been growing in the left side of his brain. Was it a cancer? Was it a metastatic tumor from a cancer somewhere else in his body? At this point, we do not have those critical answers.

Throughout the day, George was having periods of normal communication, followed by odd periods where he was speaking in tongues unknown. The hospital's only neurosurgeon met with him this morning and he is scheduled for surgery in two days. We will keep you posted.

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