Wednesday, September 26, 2007

I read the news today.... oh boy!

A while ago Orchidea asked what it feels like being the harbinger of bad news. What follows is my best attempt at a succinct(ish) reply.

Students these days spend a lot of time learning about 'breaking BAD NEWS' along with other essential communication skills. We old sweats had to pick these things up the hard way. In reality I'm not so sure we didn't get the better deal though. The thing is, there ae just too many variables you need to factor in to being an effective harbinger. In my view it is damn near impossible to role play this particular scenario effectively, simply because none of the actors involved (one hopes) can truly have any concept of the stakes involved.

The dramatic conventions of stage and screen would dictate that each such occasion is played to the hilt, with everyone in the room wearing their heart on their sleeve and the whole spectrum of grief played out in a few short minutes. As with so much else in life, reality is somewhat at variance with high drama, or even with soap opera. Life, even the end of life, is a continuum. Our scene does not begin with the director shouting 'action'. Neither does it end with the close of the office, or house, front door.

Furthermore, a great many of those for whom the bad news is intended are merely having their own impressions confirmed. Granted this is not the case for all, but my own experience has it at a significant majority. Factors such as faith, ethnicity, family support, prior family history, and both the patient and their families past life experiences all need to go into the melting pot.

Next one has to consider the relationships already built up between doctor and patient (be they good or ill), their connection to the wider practice and community, and to their hospital consultants, teams and specialist units.

From all of the above, it should be pretty clear that there can never be a one size fits all approach to the harbinger business, and we risk confusing juniors, having them believe the whole 'Bad News' agenda has been dealt with in half a day of safe and cosy roleplay.

Now, returning to the question, I have two answers that at first blush may seem rather a cop out. I hope I can show you they are not.

The first and simplest answer is 'never good'. I am frequenly accused of having a penchant for stating the bleedin' obvious, but I fear it needs stating anyhow. With all the evidence presented, when faced with a life threatening diagnosis, it can feel rather as though you sit as judge, jury and executioner dishing out arbitrary and summary 'justice'. This feeling can be even worse if, with the 'benefit' of hindsight you feel the diagnosis was in any way delayed. And it can feel worse still if you have come to know the patient very well, or, ironically, not well enough.

Which brings me to the second and rather woolier answer. The act of delivering such a verdict, as previously aluded to, is interactive, with at least two participants. As a result the scene, though it shares a number of common threads, feels different every time.

For the majority of patients as I said before, you are simply confirming their own impression. It takes some pretty spectacular mental gymnastics to live for any length of time with a significant and potentially life threatening diagnosis, and not to at least guess that somthing is amiss. It can, and occasionally does happen, and when it does we can stray into the sphere of high drama.

But for most folk, with most significant diagnoses, you move speedily from 'what' it is to 'how' to make it go away / stop hurting / slow down. This is where one turns from simple messenger to true harbinger.

O.K. I'll admit, I had to go and look it up. I had always assumed the two terms were near interchangable, all be it that harbingers carried more portentous news, harbinging as they commonly do, Doom, or Spring or some other word requiring a capital letter. And so indeed they do, or did, but they do much more than simply foretell an arrival. They are the fore-runners, the attendants sent out ahead of notable personages to prepare the way. It is their job to see to it that shelter is arranged and that provisions will be on hand to sustain and refresh their charges.

So in the imparting of bad news it behoves us to think about the aftermath, and be ready to reach out and offer what shelter and sustenance we can. Where there is hope of recovery, however slight, we must be sure to offer that hope. And where there is none, we must make it plain that there is still much that can be done to offer comfort and support for as long as it will be needed.

And in doing this well, however painful the message can be both to give and, more particularly, to receive, by showing that we can and will always try to prepare the way, it is possible to take some pride in being an effective harbinger.


Elaine said...

Orchidea posed an interesting (and challenging) question, and you have given us a very thoughtful response.

Thank you for sharing that with us

Z said...

Yes, thank you.

I remember the sweet and very young doctor who was obliged to give my mother, my sister and me dismal news. I remember most of all that the dear boy could not pronounce 'th' and repeatedly said 'growf'. But, oddly enough, his nervousness helped us, because we wanted to help him through a difficult experience.

orchidea said...

A thoughtful response from a compassionate man. Thank you for taking the time and thought needed to formulate your answer with such care.

I have an update on the chef - after sending ten days at home, he's now at the specialist unit where he'll receive a stem cell transplant in the next few days. Please keep him in your thoughts. Thanks.

orchidea xxx

orchidea said...

erm, spending

Doctor Jest said...

Elaine-- most welcome.

z-- "Growf" has to be one of the worst words to use here. As a euphemism it's completely rubbish since everybody these days knows what it really means surely... Still naivete need not get in the way if you can express genuine compassion, and then the choice of words is I guess, less improtant than the final content of the message.

orchidea-- t'es tres gentil, as ever. Thank you so much for the update on the chef. I haven't liked to ask for fear of touching a raw nerve. I do hope all goes well for him. Kind thoughts and best wishes to you both.

And please don't feel the need to edit comments. You've seen what my spelling's like after all ;-)

Dr J xxx

Z said...

In fact, in this particular case it was the right word. My mother became so well that she convinced herself she didn't have cancer at all. I can't stand such a euphemism myself, but we were able to compromise by agreeing that a growth could be benign.