The Art of Breaking Bad News Well

Jalid Sehouli

• Editorial: CRC Press
• Año: 2019
• ISBN:
  9781000699821
• Edición: 1
• Categoría: Medicina
• Categoría: Teoria, pratica e riferimenti medici

As Head of Oncological Surgery and the Gynecology Clinic at Berlin's Charité Comprehensive Cancer Center, Jalid Sehouli is one of the world's leading cancer specialists. Every day, he experiences situations in which conversations take on a life-or-death significance.

Delivering bad news is one of the most difficult tasks we face in life, especially for professionals such as doctors, police, or crisis intervention personnel, yet it is rarely touched on during training.

Over the course of their career, a doctor will hold conversations with around 200, 000 patients and their relatives that invariably involve delivering good or bad news. Either way, existential questions will arise, and the way the news is delivered is vital: recent studies show that it has a significant impact on patients' quality of life and the way they experience treatment.

Mixing his wide-ranging professional experience with personal stories, Sehouli describes the emotions and perspectives of those who have to give and receive bad news from a broad perspective. His book can be helpful for anyone who has to deliver bad news—managers, friends, or parents.

1

Who Needs This Book, and Why a Doctor Had to Write It

Contents

Breaking Bad News

Unbearable Fear

How Is Communication Taught and Learned?

A Topic That Affects Us All—Even in Private

Conveying bad news is one of the most difficult tasks we face, not only as doctors in our everyday clinical work but in practically any profession or sphere of life. But what is bad news, actually? Isn’t it much too broad a topic to suggest there is one course of action? Of course, sharing bad news is as varied as life—and death—itself. Still, a couple of general observations can be made. Everybody has some sort of story: doctors, nurses, patients of course, police, medical orderlies, firemen, employers, and even veterinarians. What do these stories hold in common? What can we learn from them, both as recipients and as bearers of bad news?

For those in the medical profession, announcing good news is not a complex challenge in itself, even if we should approach it much more conscientiously than daily practice generally permits. We often communicate good news with even less forethought than is the case with bad news, which is why I address the topic in the second, longer section of the book. Yet, giving a patient bad news without having them collapse into a deep depression—that is truly an art form for doctors. Even in a situation in which things appear “hopeless,” one can point out positive aspects about future treatment or the patient’s life without glossing over the truth. Successful conversations leave patients feeling adequately informed, supported, and cared for, bringing about a highly satisfying, positive experience for both doctor and patient. For patients facing life-threatening illnesses, an open and empathetic dialogue with their doctor can be an important tool that helps them confront their disease, an existential experience that can later be applied to other areas of their lives.

Breaking Bad News

Sharing bad news has been a common aspect of human interaction for as long as people have been communicating. Cave paintings, for example, were used to indicate that a certain place was not safe, or that a disaster had occurred at that location. Greek mythology tells the story of Apollo, the god of light: When a white crow brought Apollo the news that his lover Coronis had slept with another suitor, Ischys, the god was so enraged that he turned the bird’s feathers black forever. He also made it so the crow could no longer sing but only caw. In this case, the bearer of bad news was punished and cursed.

The Old Testament—one of the foundations of the three Abrahamic religions of Judaism, Christianity, and Islam—gives an equally grim account of communicating bad news. In the Book of Job, God subjects his loyal servant, Job, to increasingly unbearable losses and trials, putting Job’s relationship with God to a severe test. Today, the proverbial “Job’s news” is a metaphor for catastrophic news either that we find to be unjust or which has come out of the blue. At the same time, Job’s conversations with his friends, his steadfast faith—what today we might call his spirituality—his resilience, and his steadfast mind also illustrate the various resources humans have at their disposal to help them overcome difficult, even devastating news.

Given the amount of evidence for the important role breaking bad news has played in accompanying and shaping human experience throughout history, it is a minor miracle that we understand so little about how to handle it and that it is discussed so infrequently. The subject is likely too difficult emotionally and too taboo to leave more intimate spheres. To my mind, however, speaking and writing about it seem to be the best ways to do the necessary work of removing the taboo. That is why in addition to chapters with analytical or abstract advice, this book contains sections on what I believe it is that makes up our lives, as well as what it was that brought me to write it in the first place—stories that I either lived through myself or that were told to me. Such stories can give a better impression of what it is that people find difficult about communicating bad news—but also the positive aspects—more than any statistics, tables, or academic studies are able to give. These stories are set apart graphically so they can be found easily. This book can thus also be read as a collection of acute human situations and fates.

I am a person, a father, a husband, a doctor, a scientist, and a teacher; in what follows, I look to share my experiences regarding the subject of bad news and to start a dialogue with you, the reader, as both a doctor as well as a fellow human. I draw especially on 25 years in the medical profession—from my experiences as a young student up to my current position as the director of the Women’s Clinic at Berlin’s Charité hospital, where I focus on cancerous diseases in women. In sharing my encounters with women patients, their relatives, and my colleagues, I hope to bring the benefit of others’ experiences to the table as well. Whether it is as a coworker, the person who is directly affected, or an observer—we see how each of these roles overlap when it comes to communicating bad news. Things rarely have only one meaning, even when a diagnosis seems to. As varied as our occupations may be, different tasks and situations may hold much in common. When I address you as a doctor, patient, relative, or friend, try to put yourself across the table from me and observe your own feelings and thoughts.

But can one actually learn how to communicate bad news in the first place, as with diagnosing an illness or performing an operation? A variety of studies have shown that this is in fact the case, and that medical students and doctors alike stand to profit over the long term from engaging with the topic. Bad news may vary greatly—in its frequency, the level of existential threat it implies, as well as any consequences that may result. Sharing bad news is one of the most common but uncomfortable tasks a doctor faces. Over the course of their working life, a doctor will hold maybe over 100,000 conversations with patients and their relatives. Doctors can rely on checklists and professional development curricula that have been certified by recognized medical bodies for nearly every aspect of their everyday work; by contrast, there are few opportunities for continued or advanced training focusing on how one should, or might conduct these conversations. Doctors are required to pursue countless additional qualifications or risk losing their accreditation. Yet, training seminars in doctor–patient communications are not required in Germany, or in any other country for that matter. Conveying bad news is a difficult task for anyone; it is even more difficult when one either seeks to avoid doing so, or conversations remain unreflective because those conducting them have not received professional training.

It is simply not the case that one either does or does not have “the knack” for speaking with people in such a way that when they divulge bad news, the recipient is not stunned by the conversation leaving them feeling totally disoriented and hopeless. It would be better to speak about dialogue, because that is the most important part—a mutual exchange of information. A one-way conversation is doomed to fail and will not permit one’s counterpart to begin—or continue—to act independently. What truly matters here is empowering the other person to take responsibility for their own life, to become active so that they don’t end up in an emotional and intellectual cul-de-sac.

With “breaking bad news”—a term for which German has still not found an adequate equivalent—I mean communicating a piece of news that will drastically and negatively impact a person’s view of the future. From the doctor’s perspective, breaking bad news involves a difficult conversation in which the doctor knowingly has to tell a patient that he or she is suffering from a life-threatening, incurable disease. Surely, this definition is not all-encompassing or even generally applicable, as the effect of the news on its recipient can vary widely and may change according to individual factors such as the person’s previous experience, life philosophy, spirituality, degree of religious faith, age, and education. A person’s cultural context also plays an important role. Then there is the factor of the sum total and frequency of bad news, which can also influence a recipient’s attitude toward and perception of the news.

If there has been a succession of bad news, the way a person processes any given conversation depends importantly on how much time has elapsed since the last conversation, the impact the most recent news has had on their life, and/or how successfully previous talks were processed. Especially important for this process, moreover, seems to be recipients’ response to bad news. What I mean by this is how actively the person has worked to take charge of their own destiny, and whether the person also received good news during this period. The current state of a person’s health is yet another factor whose importance cannot be underestimated. All bad news shares a potential to destroy a person’s hopes and dreams; even when this may not match the actual circumstances, it can be taken as such. People may feel threatened, or suddenly confronted with a fundamentally different perspective on their future actions and interests. In my experience, doctors convey bad news much more frequently than they are aware of. Bad news, after all, is not only when a doctor has to tell another person that he or she is incurably ill; it can also be something which from a medical point of view does not represent bad news but still dashes a patient’s hopes or triggers fear.

Breaking bad news is a part of many areas of our lives—in the work world as well as the private sphere. Techniques can be learned and professionalized without losing the force of empathy or human interest, and directly learning about how to break bad news while reflecting on the process and training can all help to make this task easier, even fulfilling. This book looks to help readers develop an understanding of this crucial work and to provide both bearers and recipients of bad news with practical aides. My goal is not to devise a patented recipe, according to which each conversation of this sort should proceed, but rather to sort out the essential ingredients of a good conversation, and to develop a sensitivity for how each person—and oneself—might react.

Unbearable Fear

It must have been during my first year of clinical training; I still remember how that spring felt. I was enthralled by gynecology; in particular, complex cancer operations fascinated me. I was continually impressed by people’s ability to withstand such invasive operations and diseases.

As a young doctor, I had been assigned the medical station for receiving new admissions, performing anamnesis (when the doctor asks the patient for any medically relevant information), and conducting general examination tests for lung and heart function, after which the head doctor would perform gynecological exams. On that particular day, I was responsible for two new admissions. I asked the nurses if one of the two patients was ready.

“Gerda Müller,” said the head nurse, “but hurry up, she’s already expected for an EKG.” At 86 years old, Gerda Müller was a sight to behold; one never would have guessed her age. I introduced myself and began by asking where she had worked—I was curious to hear about what sort of job would allow one to reach such an age with such beauty. She worked as a secretary for a fashion company. Did she have children? “No, my husband and I didn’t want any, there were simply too many other things to do,” she replied. “You’ve always been a non-smoker, right?” I asked. She smiled and nodded. “No, I never smoked.” She had been taken into the hospital for vaginal bleeding. “I haven’t had my period in over 35 years, so I had curettage and now this diagnosis,” she explained, almost as though seeking to excuse herself.

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