Special delivery

When the news is bad: techniques for disclosing it with tact.

"I'll pass on a curious observation I've made about doctors in this last fortnight," the British writer Jill Tweedie said crisply, when first diagnosed with motor neurone disease.

"When they are about to tell you whatever it is they think you've got, and they gaze blankly at you as you enter the room, get your name wrong, look mildly bored or rather tetchy, thank your stars, for the chances are there is nothing much amiss. But the day they bounce up from behind their desk, rubbing their hands, full of chat and banter - man, you're dead."

Hers is a timely reminder that people never forget the way in which bad news is delivered. Although the act of shooting the messenger is out of fashion, delivering a life-changing diagnosis is still a highly stressful task for all concerned. For some specialists, doling out this news is a routine, almost daily, duty; but one never taken lightly.

"We all have vulnerabilities," says Dr Martyan Thornington, medical director of the home care programme at Sheikh Khalifa Medical City, Abu Dhabi. "It's a very difficult task."

Some physicians are excellent communicators naturally. Others have more average skills. With training, even the most detached doctors can be furnished with an acceptable, if not outstanding, bedside manner - and this proficiency is never more important than when breaking bad news.

There is no fixed recipe, admits Thornington, but the information must be presented in a way that is tailored to the patient, so they understand not only the details of the diagnosis but also the prognosis.

Do use the 'C' word

Medically speaking, cancer is one of the last great taboos for many Arab people. Western physicians practising in the Middle East will often find themselves having to reassess the notion of full disclosure, when faced with a family demanding they withhold a diagnosis from a patient. Cultural traditions meant that patients are rarely autonomous and families typically dictate the degree of information they receive.

Dr Terry Sparling, an oncologist formerly employed at Sheikh Khalifa Medical City, wrote eloquently of the battle between ethics and cultural pressures in his paper 'Caring for Fatima'. He charts the case of a 30-year old Emirati woman who presented with locally advanced breast cancer and an older brother adamant the news should be kept from her.

The first 20 minutes of the consultation, he writes, were spent; "negotiating with the oldest brother as to what I could say, so that I was satisfied that I would not be fibbing to Fatima and he would be content that I would not say something to her that was unduly distressing and might result in her 'giving up.'"

In the face of family pressure, nearly all physicians will question the wisdom of telling a grim truth to a patient. Sparling is adamant that physicians must resist being drawn into deception, for the patient's sake as much as their own.

"It's not only harmful, it's frightening [to lie]," he stresses. "If you hide the truth, firstly the patient knows, and then they can't talk about it. There is nothing more frightening than knowing something is out there and it's so bad that the family won't talk about it. And if you allow them to persist with this lie, it becomes more and more ludicrous as time passes."

Sparling's stance was that he would accommodate all possible requests short of actual deception and he wouldn't use euphemisms for cancer.

Initially, he says, Arabic translators baulked at using the word seratan (cancer) rather than warum, (a more generic term for tumour) and occasionally a family would refuse to see him. Still, the majority of families came to appreciate his approach.

"I would never lie to the patient," he says bluntly. "If you allow that, you sabotage trust and your relationship with the patient - which is the only thing you have to work with as a physician."

All in the delivery

Bad news comes in many forms. What a clinician might perceive to be a manageable condition can still be devastating to a patient. "Its an issue of your own biases," notes internist Christina Puchalski, founder and director of the George Washington Institute for Spirituality and Health.

"You and I may think that cancer is the worse possible diagnosis, so if a patient comes to you and has diabetes, you may think, ‘It's a chronic illness, it's manageable, it's no big deal.' To that person it could be a big deal."

The realities of breaking bad news are that it often has to be done out of hours, during emergencies, and by unprepared and panicked junior doctors. Private interview rooms may not be available, and the needs of other patients may require attention. While there is no fixed template to simplify the task, there are some common errors that can be avoided.

● Softly, softly...

Nervous physicians can overwhelm patients with clinical information after delivering the diagnosis.

"Don't throw too much information at once," advises Puchalski. "Once you've said something like 'You have a serious disease- you have cancer,' many people will almost go into shock at that point."