Accompanying Report: Delivering The Bad News, by Andrew Thurston, M.D.
Friends and family often wonder how I can give bad news day in and day out – how I can stomach it, how I can come home at the end of the day and not feel crushed by an overwhelming sadness. How I am happy and satisfied with my life, and not perpetually depressed.
“How do you do it?” they ask. “How do you tell people they’re dying? Isn’t it hard? Doesn’t it make you sad?”
I’ve often reflected on the nature of my work, and the honest answer is: yes, it makes me sad. Immensely. Sometimes so much so that I think of nothing else for days. For months, even. But as I dive deeper into my career, I find myself clinging to this sadness. It’s something I hope to never lose – this visceral reaction to suffering, the overwhelming humanity of it all.
I think the day I stop being humbled by death is the day I must move on in life.
But what many don’t understand is that it’s not the delivery of bad news that’s hard – it’s what happens after the delivery that’s the challenge. The bad news itself is just words. Syllables strung together, sometimes not even a complete sentence. The actual delivery of bad news can be as simple as dropping a package off at a stranger’s door – you can toss it from hand to hand, kick it around a bit, watch it land in a heavy lump on the ground. You may think it crass and insensitive, but I’ve seen it done before. I’ve seen people hurl the news at the door and walk away, only to watch from a distance as the family struggles to carry the thing inside, and find a place for it in their lives. I’ve seen it done because I’ve done it myself, before I knew any better.
My approach is very different now – evolved, in many ways; it has matured with time and experience, and is, hopefully, more respectful. I am now an obsessive preparer. I make sure people are home, I make sure the timing is right. I carry the thing into their home, help unpack it for them, answer any questions, figure out where it might fit in among their other things. And I make sure to stick around for as long as I am needed, waiting and listening as they cry and shout and react in their own way – not wanting anything more in their already overcrowded lives.
The delivery of bad news is not the hard part (though there are many ways to deliver it gently, and many other ways to break it) – it’s wading through the emotional flood after the delivery that’s tough. It’s the reason why, I think, many physicians hate giving bad news – because it can be so uncomfortable, so vulnerable, so very raw.
But more than this, I suspect that the moment after bad news is delivered is the one time in medicine when physicians feel completely and utterly helpless- no longer in “control” of the situation. A physician crosses a boundary in the moments after bad news – an emotional threshold of sorts, entering into the often unexplored psychosocial-spiritual domain of the patient as a person. It’s unfamiliar territory, and foreign, and can be – at times – a frightening place. I suspect that many physicians see a reflection of their own humanity, and mortality, in the eyes of their dying patients: a reminder that all life, and all medicine, ultimately answers to the same end.
I wonder if many physicians give bad news and then awkwardly leave, or spend the time sidestepping emotional land mines, due to this discomfort and vulnerability. I wonder if many physicians talk instead about tangible things in tangible charts, things like creatinine and white blood cells, due to a fear of the unknown.
I wonder if avoidance is the most effective, or perhaps most accessible, coping mechanism for some.
I used to take this path of least resistance, but it doesn’t work for me anymore. I think avoidance would just feed my inner dialogue, and I would shuffle home at night and sit in a dark corner and think about all the suffering I had seen. These days, I face the emotion head-on, not only because I’m convinced it helps patients and families deal with a difficult situation (though this isn’t always the case), but because I’m convinced it helps me deal with the stress of death and dying. When I take the time to sincerely listen and explore the terrifying implications of the end of life, I often feel like I’ve helped families find some clarity in the chaos- some “good” in a “bad” situation. And this helps me go home at night, be with my own family and play with my son without a heavy heart and without limbs of lead.
Of course, there are days and there are situations from which I walk away unsatisfied, and unfulfilled – I think I would be a hopeless optimist, and a little bit of a fool, if I said otherwise. But I find myself, over time, better equipped to handle these days – in part because I’m not entirely altruistic in my work. I realize that I have to take care of myself – as a person, as a husband, as a father – so that I can take care of others as a physician. And so the things I do – the planning, the conversations, the debriefing and the emotional exploration – are as much for me as they are for my patients.
In the beginning, when people asked me if I felt sad or depressed by the work that I do, I said no, not really. Now I say yes, it makes me sad – but I’m not afraid of feeling sad. In fact, there are times when I need to know sadness – heartbreaking sadness, perspective-redefining sadness – because maybe, in some small or perhaps significant way, exploring the murky depths of death helps me better appreciate and cherish what we, as people, can have in life.
And because, at the end of an often very long day, what I do for a living is ultimately more about life itself than it is about death.
Andrew Thurston, M.D., is a Clinical Assistant Professor of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics at the University of Pittsburgh. He completed his medical school training at the Baylor College of Medicine, and his residency at Northwestern Memorial Hospital. He subsequently completed a Geriatrics Fellowship and a Palliative Medicine Fellowship at Northwestern Memorial Hospital.
His clinical activities include supportive and palliative medicine inpatient consult service at UPMC Mercy Hospital.
Current areas of interest include the application of palliative principles to geriatric syndromes and disease, and the incorporation of literature and civic reflection in medicine.