Break Bad News with Love and Compassion

Based on?The Clinic?with Dan?Lieberman,?a new show that?premiers?January?21, 2022,?on Phoenix Spine and Joint?youtube: https://youtu.be/biCHUJAkuUI?

• ?Start by listening?
• Wait for permission?then tell the truth?
• Set the scene with compassion?

The first time I told someone their loved one?died?I?did not?know what I was doing. Literally. And it?didn’t?go well.??

It was three o’clock in the morning,?and?it looked like?I was going to have to?work all night.?As the?surgical?intern on the trauma?team,?I was the?first-year?doctor responsible for making the hospital work; for writing the orders to move patients to where they needed to be to get the right care.?I?just?came out of the operating room of a patient that?didn’t?make it. Despite being?not much older than me, in her?late-twenties, the?injuries she sustained to her abdomen and chest?in the car accident?were so severe we?could not?stop the bleeding. She died on the table.?As I collapsed into the chair at the?front desk?of the operating suite?the phone rang.??

I could have ignored it. It?was not?my desk?or my?job. And I was half asleep. But I picked up the phone.??

“Hello.”?

“Hello,” I said.?The?phone?line?was for the front desk, and not?available?to patients.?

“I’m looking for Maria Sanchez.”?

“The lady in room three?” I had?just?come out of that room.?I knew her by her trauma name. A code that was made up by the system for people who were unconscious. I was not totally sure, but I thought that Maria Sanchez was the patient's real name. The caller did not?identify?herself.

I assumed?the caller was the bed control nurse?looking for an update. That's the only person I could imagine would be calling a backline in the OR before dawn. The computer?needed to be updated as?to whether the patient was going to a room in the?recovery?room,?hospital ward, or to intensive care?from the operating room.?

“Yes.”?Normally she would go to the recovery room and then a decision would be made about disposition.?But this patient?was not?going to any of the usual places.?This was an unusual situation. This patient was dead.?

“Oh,?no. She died,” I said.?“They’re?coming to take the body to the morgue.” Silence.?The?long?silence made my mind race.?“Who?is this?”??

Then came the shriek.?

It was a cry of?pure?agony. I had no idea who that person was, or why?they?cared, but their heart was?broken. And their grief exploded into the phone.?“Who...” before I could finish the?sentence?she hung up.?

As I?put?the receiver down on the phone my heart sank.?I had no idea how a family member ended up on a backline?at the OR front desk. But the cramp I felt in the pit of my stomach is what you get when you hurt?another person. As I sat there my head was reeling. How could I?have been?so cruel???

I?will never forget?that moment. Or the pledge I made to myself to never let that happen again.?Breaking?bad?news?is not just for doctors.??

When you?must?fire someone,?let somebody know that?they are?not getting the promotion that they were counting on, or even that they?didn’t?get the deal,?you are?breaking?bad news.?If you are a?leader,?you?cannot entirely avoid having to?break?bad?news?at times, but?you would?naturally like to do so in as humane and kind a way as possible.?

Unfortunately, over my?twenty-year?career as a neurosurgeon, I had a lot of practice. I told hundreds of people that their loved one was dead or dying.?Hundreds?more that they were the?ones who had a problem?with?which they were going to die.?And thousands that they would not get better without having to undergo surgery.?After that night in the operating room, I made it a priority to see what worked, and what?did not.?Over the years?I found out?that it never stops hurting, but if you pay attention and work at it, you can learn to break?bad news?with the kindness and compassion that its recipients deserve.?

Start by listening?

You?cannot?just?vomit?out with the?bad news.?Sometimes when we feel?nervous,?we want to just get it over with. If you blurt?it?out,?you are?likely?to provoke an extreme reaction and create the worst memory of someone’s life. Instead, introduce the subject, then?let the other person talk. This is particularly true if you?do not?know the person; you?must?establish?a?relationship before you can really communicate.??

Begin by?establishing?rapport and credibility with unambiguous facts. “I understand there was a car accident,”?I said to him.?People?need?to tell?you?their?story.??

“I was at work and the police called,” he explained. “I?didn't?have my?car,?so I had to Uber. There was a lot of traffic.” The?details?of how a husband whose wife arrived at the hospital brain dead?didn’t?matter to me?as the doctor taking care of his wife,?but it?mattered to him.?He?needed to?settle?down. We get control?of ourselves?by doing routine things, like talking.??

It does not really matter if it's not the information you want; if someone offers you their story, be gracious and accept it by listening.?Once someone gives you permission by asking a worse case question you should?answer it while being?calm, compassionate, and truthful.?

Wait for permission?then?tell the truth?

There is no sugarcoating it, receiving?bad news?is an injury.?It hurts.?And the recipient is likely to never forget the moment you tell them.?They?may not have a choice, but?you?can give them the respect?of still?having?consent.?All of us have our own way?of?getting ready. Even if you know someone well you still?do not?know exactly what they are thinking.?Use body language to foreshadow the bad nature of the news.?And stick to the facts.??

“When the ambulance brought your wife to the hospital she wasn’t breathing on her own,”?I told the husband. He nodded at me. His nod was his communication that he could handle more information.?“A CT scan of her brain showed extensive damage.” He exhaled and leaned back in his chair and looked me in the eye. His silence while making eye contact was my clue to continue. “When I examined her there were no signs of life.”??He looked down, put his face in his hands, and started to cry. His mother lived nearby and came?to the?hospital. I had her sitting next to him. She put her arms around?him,?and she cried too.??

I froze. I would not go on until he was ready. And I knew he would tell me when it was?time.?When?they are?ready to hear it,?people?usually?phrase the worst as a question.?After a few minutes of?silence,?the husband looked me in the eye.?

“She’s?not going to make it, is?she, doc?”?

All our lives?we are?taught not to hurt others. In giving?bad news,?there is?a tendency to avoid injury by not telling the truth.?Or even to be vague. “Oh, we’ve done?everything we can for her.” That may be true, but it?does not answer the question and?kicks the can down the road.?Once someone gives you permission by asking a worse case question you?should?be?calm, compassionate,?and?truthful.??

“We see a lot of people here?after?accidents like?the ones your wife?was in. Most of them?don't?make it.?There was nothing that you or she could have done differently, this was a horrible accident. But according to my exam and tests we have done she has passed away.”?His mother and I held him until he could talk again.?

?In every situation, all of us are human beings, and we deserve comfort when we face pain?and suffering.?

Make sure the person has what they need?for support?

A jail psychiatrist I met in medical school told me he carried cigarettes with him despite not smoking. This doctor spent his days interviewing people?suspected?of violent felonies to see if they could be psychotic. His exams were done in?five-by-five-foot?rooms alone with the perpetrator.??

“I?don’t?get it.?Why do you carry cigarettes if you?don’t?smoke?” I asked.??

“People don’t attack you if their needs are satisfied,”?he explained. “In twenty years of doing this job?I’ve?never been attacked. Nobody else who does this job can say the same.”?

All I can say is that you do not need to hand out cigarettes. But you want to?anticipate?someone's?needs and make them feel as comfortable and supported as possible.?I waited for the young husband’s family to arrive before I spoke to him even though I knew his wife was already dead.?

Treat people the way you would want to be treated.?For example, if?you let?someone?go from?the?job?he loves because he works?at?the desk next to his best friend, make sure his best friend?is at?work?when you give him the?bad news. He will choose whether he wants to share it or not. But it may help to have someone to?get?him?home.

Protect their privacy, but also be?sure?the?person has?a support system available, whether?it is?family,?a?friend,?clergy,?or?in the?worst case a?nurse or social worker.?In every?situation, all of us are human beings,?and we?deserve comfort when we face pain.?

No matter how often you do it, it never gets easy?to give?bad news. Human suffering is just?painful. But it?does take the edge off to be kind and compassionate.?By listening before?talking,?you give?people?a chance to steady themselves and settle in. You know?they are?ready when they ask a question that?anticipates?the news. That question is your consent to tell them?what is?happening. As always, treat people the way you would want to be treated if it were you, give them a tissue to dry their eyes and make sure there is a support system in place?for?comfort.?

Life can be harsh.?But we are all in this together. By taking a few important preparations you avoid making it even worse.?In my YouTube?show?“The Clinic” now playing on?the?Phoenix Spine and Joint?Channel?I recently had to tell a patient he had a malignant tumor. That episode will premier on February 7, 2022. To see how these principles are applied come see the show.

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Dan Lieberman, MD is a writer and Medical?Director?at Phoenix Spine and Joint. Dr. Lieberman studied mathematics/computer science as an undergraduate at Pepperdine. He received his MD from the?University?of?Arizona and?worked as a government scientist at the National Institutes of Health. He trained in neurosurgery at the?University?of California at San Francisco and practiced in Phoenix, AZ until 2020. After retiring from neurosurgery due to essential tremor has pursued writing?fiction and?is the?Medical?Director of Phoenix Spine and Joint.??

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To see the video check out?Episode 1: The Clinic with Dr. Dan Lieberman, Jon Rogers, SPINAL STENOSIS.?

To learn more about spinal stenosis check out our blog:?The Clinic Archives - Phoenix Spine & Joint (phoenixspineandjoint.com)?

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