My mother swam every weekday for years, kept her figure, and ate salads. “But she’s so healthy!” was the standard response among her friends when, in her late seventies, we learned that she had an especially difficult cancer — of the bile ducts — which had already spread.
She persisted in thinking that she would survive this illness, though she never had a chance. I knew the truth only because I asked her doctors for specifics in a private telephone call, and presented them to an oncologist who wasn’t treating her, the father of a college friend. He was frank. My mother’s doctors didn’t lie — but they also weren’t frank or explicit.
How should doctors deliver bad news? Oncologists shoulder that job thousands of times over a career, with very little training, although some medical schools teach students a mnemonic called SPIKES, a six-step protocol for delivering bad news.
If you are accompanying a friend or family member to a doctor’s visit in a frightening situation, you can help by tactfully guiding the doctor.
Be sure the meeting takes place in a quiet, private area. You might give your loved one a cup of hot coffee or tea to hold. The warmth is comforting and encourages the perception of other people as emotionally warm, generous, and caring.
Be sure the doctor asks what the patient already knows about her situation or reviews the information so far.
If the doctor is using medical jargon, ask for clarification. You might say, “I’m sorry to interrupt, but I didn’t follow that,” or “Could you boil that down a bit?” You might do this even if you think you understand, to be certain there are no misunderstandings. Simpler language will be easier to repeat to other family members. But don’t push too hard. As a reporter, in early meetings I tended to ask my mother’s doctors to answer questions like “And if this happens, then what will you do?” until I saw that I was only distressing my parents and her doctors.
A doctor with a talent for delivering bad news will acknowledge emotions with silence. If you feel rushed or suspect your loved one needs more time, you might say, “I need a minute.” Many doctors keep talking while the patient is too stunned to hear much at all. Having a moment to let the news sink in always helps.
Many doctors adopt military metaphors, for instance, calling the immune system a defending army. The idea goes back as early as the 1600s when the poet John Donne wrote of illness as a cannon that “batters all.” A 2010 study found that physicians speaking to patients with advanced cancers used metaphors in nearly two-thirds of their conversations. The patients regarded doctors who used more metaphors and analogies as better communicators.
You can’t be sure how your loved one will react, but you might let a doctor know tactfully if you think fighting metaphors will back-fire (see what I mean?). Seeing cancer as a “challenge” rather than an “enemy” was linked to less anxiety and depression three years later, in a study of 1,012 Canadian breast cancer patients. Many patients feel obligated to be upbeat, other research suggests. Fighting metaphors may encourage them to hide their distress.
Recognize that doctors can also be emotionally overwhelmed in these situations. I was surprised at how much discomfort I saw in my mother’s doctors. Next time I deal with a family member’s bad health news, I hope I will remember to try to signal with my body language that they’re doing okay, that I know it’s not their fault. As a third party, you can be a bridge, which may be essential when decisions must be made.
My mother’s doctors did not use metaphors. They were factual and courteous and avoided the bottom line. She insisted that she would survive. I suspect she wasn’t pretending, and that her doctors did her a service by allowing her a fantasy. We didn’t face the question of hospice care; she died too quickly, two months after the first bad news.
June 24, 2015
Janet O’Dell, RN