The Bad News Room

A reader asks:

On rare occasions, a doctor won't say anything while I'm on the tissue-covered table and silently escorts me to a small room with ugly upholstered furniture for a conversation. I think the idea is that this is a more "comforting" environment, but to me, it's just another strange medical space. Perhaps you could explain how your compatriots decide where to speak to patients?

Yes, some doctors have this weird idea that bad news is only tolerable when given in a sitting room with upholstered chairs and fake plants.

The trouble, of course, is that patients suspect this and therefore getting moved to the little room with comfy chairs significantly worsens your already nerve-racking visit. You know the bad news is coming, so the comfy room feels like a cell where you await your sentence.

As I've mentioned before, giving bad news is always a rough part of this job. We want to be as gentle as possible, but I think the little room is more for our comfort than yours.

Doctor D believes the most important thing about news is to give it straightforwardly and in a private place. Last thing your doc needs to do is to give it in crowded ER when your neighbor is listening on the other side of the curtain. Of course, the small, busy ER where Doctor D works has lots of curtains and no cute little room. D has even been known to take people in the medicine closet for a talk when it's the only safe place to protect their privacy.

But when privacy isn't a concern, the last thing I want to do is move you somewhere where you know you are waiting for bad news. I'll tell you straight up what I'm thinking. Doctor D believes people care more about hearing news directly, honestly, and kindly than they do about the location where they are told. I have used offices or these little sitting rooms in the past, but only because the patient wanted me to tell a lot of family members that wouldn't fit anywhere else.

I start directly and tell you straight up wherever we are. I know their will be lots of further discussion and questions. I'm always glad to finish the conversation wherever you would prefer to talk.

What do you think? Would you be upset by being told in an exam room sitting on that tissue-covered table? Would you prefer to be moved to the room with the comfy chairs? Let Doctor D know if he should change his strategy!

What Are My Chances, Doc?

As you may recall from the last post, if Doctor D suspects you might be facing a lethal illness he'll let you know straight up. He brings it up gently, pointing out that any doctor's guess has a lot of uncertainty.

You do, of course, have the right to ask, "How certain are you, doc?"

But here's the secret: MDs hate answering this because we often don't know how certain we are. I'm usually pretty good at predicting what will kill a patient. How good? Results may vary...

In a few diseases there is solid data: 80% of people diagnosed with pancreatic cancer will be dead one year later. Usually, however, the situation is too complex and there isn't any research data to answer the question. Then Doctor D whips out a gut guess.

I once had patient with curable but advanced colon cancer develop urosepsis and then have a heart attack from the septic shock. His family wanted a percentage for his chances. I made one up, "Maybe a 40% chance of surviving the next 24 hours." He survived and went home.

As I said, I'm not perfect.

Percentage numbers don't really mean that much when I'm guessing, but people just like something that sounds mathematical rather than “almost certainly dying” “could die” or “maybe dying but probably not.”

Predicting death is a risky business. Doctor D once had to dodge a fist when D told a dude his dad probably wouldn't make it. (Fortunately crying people can't pull off a good sucker punch!) Doctors also don't like mentioning death because most people don't like to discuss about their own mortality. We vaguely acknowledge we all die sometime, but you don't expect "sometime" anytime soon. Then Doctor D sits you down and says, “Now might be your time.” It's never an easy talk, and it's almost always based on an educated guess.

Doctor D still thinks it is worth letting you know, even if his estimations aren't perfect. Most patients want to prepare themselves and their families if death is a real possibility. I only withhold such information if a patient told me ahead of time they don't want hear any discussion of death.

What do you think? Do you want your doctor to tell you your chances? Even if it is only an educated guess?

Some old MDs never mention the word “death” because “they don't want to take away hope.” Obviously, Doctor D takes the opposite approach. Which would you prefer? For yourself? For your family?