In about the third year of medical school, you are taken to one side and taught how to break bad news to patients. This teaching involves important suggestions, such as:
Ensure there is a box of tissues handy
Make sure you give the patient an opportunity to speak.
There’s even a handy mnemonic, just in case you temporarily forget how to be a human being.
I have sat and listened many times as many patients are told that their cancer is going to kill them. I have heard the consultant fire a warning shot (I’m sorry Mrs Jones, but I have some bad news) and I have witnessed the breath-taking silence which follows these words, as we all wait for the patient to respond.
You will never hear a silence quite like it.
When the patient finally speaks, it is always to offer up an opportunity for hope. They quote their friends and the internet and things they’ve seen in the newspaper. They tell you stories of people they’ve read about, who have defied the laws of medicine but who never quite made it to the front cover of The Lancet. Lastly, when the consultant has cruelly shot down each of their sentences with jargon and statistics and test results, they give you their final fragment of hope.
“They’re always making amazing new discoveries now though, aren’t they?”
They always say this.
The consultant then smiles at them patiently and offers information leaflets and an appointment with the palliative care nurse.
It is at this point, the patient is expected to be brave. It’s in the contract. If you are told you are going to die, society dictates that you take it on the chin. It makes it a lot easier for everyone if you don’t make a fuss. We can then sweep you into a corner of the ward and tell everyone how stoic you’re being. Doctors like stoic patients, because it makes them feel a little better about losing out to God.
A very experienced consultant once went into one of the side rooms and told a young woman that she was going to die. The cancer was marching through her body, climbing her spine like a well-trained army and crushing each vertebra on the way to her brain. There would be no amazing new discoveries for her. This would be her final Christmas with her family and, although she didn’t know it at the time, she had already lived her last summer on this earth. The woman in the side room clearly didn’t read the contract. She wasn’t stoic, she was angry and vengeful and sour. A few days later, when the woman in the side room continued to snap and cry and criticise the unfairness of it all, the consultant considered her behaviour to be unreasonable.
I’m not entirely sure what constitutes unreasonable behaviour in these circumstances.
If someone told me that I was going to die, that cancer was rushing around my body at full speed, as if it had a very important bus to catch, I rather think I should be unreasonable too. More than that, I think I should shout and scream and throw furniture, because I didn’t sign the contract either.
We expect cancer patients to sign the contract. Society pressurises them into it. The language of cancer is such that patients battle and fight. We talk about cancer in hushed tones, lowering our voices and speaking very quickly, just in case the cancer hears us and gets big ideas about itself. Cancer patients raise money for other cancer patients; they smile for the camera and make jokes about losing their hair, so we all feel more comfortable about life and if they are fortunate enough to win their battle, they become a survivor and are paraded around to ensure everyone else remains stoic and reasonable.
I admire these people, I honestly do. I cannot begin to tell you how humble I feel when I read their stories. I just worry about the ones who are left. The ones who didn’t read the fine print.
There was once an elderly gentleman on the ward, who was edging through the last days of his life. He had a huge army of healthcare professionals who visited his bedside on a constant circuit – oncologists, urology surgeons, palliative care nurses, dieticians, physiotherapists, pain management specialists – all making sure he was dying the proper way and not letting the side down. For each one, he brought out his best brave face. With the little energy he had left, he would smile and nod and talk about making the best of things. He knew he was going to die. He just wasn’t allowed to do it in peace.
When they had all gone, I went over to talk to him and asked him how he was feeling. He told me to draw the curtains and when I had, he took my hand and spoke very quietly, just in case the rest of the ward could hear. He said:
“Jo, I’m scared.”
And he was ashamed.
They don’t teach you how to answer that at medical school. There’s no handy mnemonic or useful worksheet. Along with our degree certificate and a subscription to the BMJ, we also sign an unspoken contract to be distant and dispassionate. As doctors, we are not taught how to comfort or care or cry with someone who is afraid of dying.
I think perhaps we should be.