Brave Faces

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

and

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. 

Always.

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.

Comments

  1. There has been / still is a lot of Cancer in my family and other illnesses that taken lives of precious loved ones. I think there is much to be said for spending money to make sure someone (I don’t know who) is there to hold the hand / to cry with / to be the confidential listening ear. I think that this would be so much more valuable than spending many £1000’s of pounds on new drugs which may extend life by a few months at most. In a world which does have limited resources, I do not think infinite spending to achieve a small (perhaps 1 – 3%) increase in lifespan is the right approach. Spending a lesser amount to ensure emotional support, pain management and dignity (continence etc.) are provided is more important.

  2. Oh, Jo, how dreadfully rotten for him, and how rotten for you having to deal with it. I don’t see how there can ever be an answer in that situation. There just needs to be someone there.

    (((hugs)))

  3. It is such a privilege to read your compassionate and articulate posts – I do hope there are fellow medics and medical student teachers reading them as well.

    “As doctors, we are not taught how to comfort or care or cry with someone who is afraid of dying.” – I’m not sure that these things CAN be taught, they come naturally to some people, such as yourself. I agree with Mick that resources might be better spent/shared on providing patients with access to someone who cares, rather than someone who is unable to deal with their inability to cure.

    Your patients are fortunate to be in your care.

  4. You are going to make a damned good doctor. I know I would have been tempted to say, “I would be scared too.”
    It’s okay to be scared because it is another way of being brave.

  5. The medical profession really needs to hear this.

    I recently had a painful procedure (a hysteroscopy). The doctor promised that after the last one I could have this one done under a GA but she went back on that, wouldn’t even let me have sedation. So I took ultra-strong painkillers.

    She then said she would only take one quick biopsy and not bother with pictures as she knew I was worried about the pain. What did she do? Take a mass of pictures and several biopsies. When I queried this afterwards (I wasn’t told at the time that this was what she was doing) she said it was because I was “doing so well”. I.e. not screaming. I did scream once, “Christ, that hurt!” but they chose to ignore that. It wasn’t in the script.

    Afterwards when a nurse asked me how I felt I said “crappy” and she laughed. It had to be a joke, because being genuinely in pain or not coping isn’t in the script.

    Some doctors get it. We need more that do.

  6. Your writing really brings home what it must be like to work in the medical profession, and how the harsh realities of life and death situations affect you. I’m full of admiration for those who choose to follow this path.

    I’ve often wondered how I would react to being given such news – I doubt that I would be stoic and brave either.

  7. I am very grateful to the lovely Simon Ricketts for recommending your blog & spent a good hour before bed last night reading through your posts. This one holds a particular resonance for me as eleven years ago we were given the news, by a dispassionate team of gynaecologists & paediatricians, that our first baby had Potter’s Syndrome and would die shortly after birth (see my last blog post). I was diagnosed at 30 weeks and brusquely informed that I would have to “be brave” and carry on with life as ‘usual’ until my baby was born; he was a full term baby. I was offered no counseling in the interim and when I went into labour, was put in an ante-natal ward with six other ‘healthy pregnancy’ women. We were actually told by one paediatrician that the hospital were “quite excited” by us as Potter’s is relatively rare and they hadn’t had a case in 15 years. When Jamie was born and it turned out that he also had sirenomelia, the hospital team were positively ecstatic. Our delivery suite was like a St. Patrick’s day parade ground with the amount of interns marching through.
    At the time, my husband and I were both too raw with grief to show much anger, but my dearest friend, who is a senior nurse and who was with us for Jamie’s birth later wrote a five page, strongly worded letter to the hospital. Even she sadly acknowledged that it would probably be read by one person and put straight into the shredder.
    I understand the need for a certain degree of detachment in the medical profession and have nothing but the highest respect for those who work to save lives in often under-funded, over demanding conditions, but when patients are presented with the worst possible news even the smallest gestures of compassion & empathy go far. Thank you. xx

  8. When I was at Medical School there was no training at all on ‘Breaking Bad News’. None. I remember when I was a medical house officer I was called to the ward by the Sister and asked to go and inform Mrs Jones’ family that their wife/mother was dead. In those days it was always the doctors job even if the doctor didn’t know Mrs Jones from Adam and had never met her family. I couldn’t believe they were expecting me to do this. I opened the door to the room where her family were waiting and was greeted by a sea of expectant, desperate faces. I blurted out ‘Mrs Jones is dead!’ and promptly burst into tears.
    Since then I have learnt some techniques, and indeed have been responsible for teaching them for many years to juniors and on ALS courses. There are right and wrong ways to break bad news but ultimately, as you say, it comes down to being a compassionate human being. I still find it the single most difficult part of my job and I still cry, almost every single time.

  9. When I was a nurse I worked in A&E and breaking bad news was unfortunately par for the course for the young SHO’s. However, it was more often than not to tell the relatives that a family member had died. There were no leaflets or pamphlets guiding them and it was often left to the experienced nurses to tell them what to say and how to say it. There is no right way to break bad news, but bad news often needed to be given and the relatives always needed to be told. In my experiences, information was of comfort to the relatives, it was the beginning of the grieving process and often helped them to come to terms with the unexpected. When it came down to it, the doctor who had cared for the patient (albeit briefly) gave the bad news. They were always accompanied by a nurse, who had to witness the uncomfortable attempts by the doctor who would fumble through, trying to explain what sudden and often unexpected event had taken place, which had cut short the life of their loved one. It was incredibly difficult. However, the doctors often tended to hide behind medical jargon, then they would leave me to try to explain what had happened in layman’s terms and comfort them. I often spent the rest of my shift with relatives, making tea, holding their hands telephoning friends and other relatives, and I often cried with them. I didn’t mind. But I must admit I really don’t miss that part of the job. Seeing peoples lives completely shattered and beyond repair and being unable to do anything is horrible, but I sought comfort by hoping that what I did helped the relatives just a little bit.

  10. This was nothing like so serious, but when the consultant told me I had lost the sight of an eye (completely non disabling by the way) I asked if it would look odd. He said it might wander about a bit, in which case they would take it out and give me a glass one. I was in intensive care at the time, but I summoned up my strength and told him if he said anything similar to my mother I would come after him (I hope I mentioned a hatchet). He looked rather surprised.

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