I met my friend Ann through swing dancing. She lives here in Chicago with her husband and she is in Medical School at the University of Chicago. Last Sunday she wrote this and I think that it’s very well written. Almost as if I were there, feeling and thinking and saying these things myself.

I know very few people who are this brave. Most of us are afraid of things that make us truly vulnerable. Ironically, I believe that life knows no greater fullness or significance than that which follows terrible sadness. And I think that most people - by their fears - inoculate themselves against ever really living.

It’s interesting to read and feel this against the backdrop of my wedding, which is only 24 days away. In one glance I see both the greatest celebrations and deepest injustices of life. I see a young couple in love who are devoting their lives to each other, and at the same time, I see an old couple in love whose dreams are abruptly cut short. Ann’s paragraph about the words “I’m sorry” is so vivid.

I have found a deep happiness in life. Right now it’s the time for Erin and I to celebrate, and believe me - we’re going to celebrate wholeheartedly!

But I still find this whole thing provocative; it really makes me think about life.

Delivering Bad News
Sunday, May 11, 2008 at 1:26pm

Two days ago I delivered bad news to my patient. This was the first time I’ve ever had to say such a thing to someone in a real life situation. My resident and I walked down the hall towards my patient’s room. She said “Do you want to do it?” I said “No. No, I definitely don’t. I haven’t even watched someone else do it yet!” My resident said nothing. “On the other hand, I know the patient well. Maybe I should do it. We have had all these talks on how to deliver bad news. I think I could do it. I even think I could do it well. You’ll back me up if I miss anything?” I asked. “Yes, I’ll be there with you. I’ll back you up,” she promised. “Ok,” I agreed. “I’ll do it.”

My patient came in to the hospital on Wednesday morning and it was now Friday. She had arrived at the hospital to visit her husband who had just had a big surgery for his cancer diagnosis. She arrived on his floor short of breath and the nurse sent her down to the emergency room. She was admitted to my medicine service the same day so she ended up having to stay in a separate room on a different floor from her husband. We wanted the two of them together when we delivered this news and she was the more mobile of the two.

We reached her room and she was there. My resident said “Hi, Ms. P. We need to talk to you. We thought we’d walk you down to your husband’s room so you could be together while we talk. Is now a good time?” My patient was about to go to the bathroom so we waited for her and told her nurse we were taking her off the floor for a bit. My heart started pounding as I thought about what I was going to say. Memories of a video we watched on delivering bad news came back to me. I turned off my cell phone. I turned off my pager. I wanted absolutely no interruptions. What was I going to SAY to my patient as we walked down to her husband’s room? She was sure to know bad news was on its way. How could I make the walk & conversation less awkward? What could I say to distract her from being afraid?

Ms. P finished with the bathroom and came out of her room. Her IV’s had medication running into them so her left hand was occupied by dragging her IV pole around with her. We smiled at her. I made jokes about absconding with her from the floor. That got us all the way to the elevator. As we rode the elevator down, we talked about her IV pole, and how her friend had to leave the hospital with one. Her friend had named the IV pole and I asked her if she’d named hers. She hadn’t. The elevator doors opened. We talked about her husband and his care as we walked down the hall towards his room. She said his nurses had just started giving him a blood transfusion. She’d had a blood transfusion before so she had been telling him over the phone how much better she’d felt after she got her transfusion to reassure him. Despite needing her own medical care, she was still doing her best to support him as he recovered from surgery.

I’d met Mr. P the day before when I went to his room to retrieve Ms. P’s book for her. Mr. P had sent me back to his wife with all of the flowers from his room. He was allergic to flowers and wanted her to have them anyway.

We reached his room. His own nurse was there, setting up the transfusion. He was sitting in a chair next to his bed. He had his own IV pole with a bag of blood hanging from it, running in to his arm. He was awake and alert although he looked tired and pale. My resident walked into his room and introduced herself. “Look who I brought you!” she said with a smile. Ms. P walked in to her husband’s room. On seeing his wife, he brightened. “We wanted to talk to you together so we brought her down to see you,” my resident continued. We started arranging the room for the delivery of the news. Recalling the video on delivering bad news, the person(s) delivering the news were supposed to be sitting at eye level with the patient. We pulled a chair up for Ms. P next to her husband. I pulled up the remaining chair and sat facing them. My resident lowered the husband’s bed so that she’d be at their eye level and she sat on that.

Oh God. My heart started racing. My palms started to sweat. I thought to myself “Cut it out. Just tell them as nicely as you can without beating around the bush. They have to know. Be kind. Just tell them.” Between the time that my resident sat down and I began speaking, no more than 3 seconds could have passed, but they seemed like the longest 3 seconds ever to me. My heart stopped racing and I opened my mouth.

“We wanted to talk to you together because we got your test results back.”

Now I was supposed to give a warning word so the patient would know that something bad is coming. Something like “I’m sorry to tell you, but…” or “unfortunately…”

“Unfortunately,” “your test results showed atypical cells that indicate metastatic cancer.”

There. I said it. Cancer. We were taught not to couch this word or hide the diagnosis by saying something like “There’s a mass in your lung.” Out with it. Say the word cancer. Be clear.

I watched my patient receive the word, cancer. I watched her look at her husband. He looked back at her. They were holding hands. There they were, a married couple in their late 50’s with no children, dressed in their hospital gowns, both attached to IV poles, sitting in hospital chairs, holding hands, and hearing that she has cancer. I waited for them to look back at me before continuing.

“We don’t know what the source of the cancer is yet. We think the most likely source is a new lung cancer. It could be of a different source that we haven’t found yet. It could also be a recurrence of your previous cancer, but we think this is unlikely because it would appear in the lymph nodes in a different part of your body first and we haven’t seen that.”

Then I reviewed her CT scan results with her. She’d gotten a CT scan when she came into the emergency room because the doctors were worried she might have a pulmonary embolism. She did, as it turned out. Unfortunately it had also shown a giant mass in her lung, nodules all over her lung, and hypodensities in her liver which we guessed were probably metastatic cancer. No one had told her about the spots on her liver or about the big mass in her lung. I knew she didn’t know about it because I’d asked her for her understanding of her CT scan results when she first arrived. For the 3 days she’d spent on my service I’d been thinking about why no one told her about the lungs mass or probable liver mets. With just that image we couldn’t PROVE to her that she had cancer. We just thought it was extremely likely, especially given her smoking history. Maybe being in the loud emergency room, alone, and having a doctor you don’t know tell you that you PROBABLY have cancer that has metastasized isn’t the best way to find out. Instead she had come to the floor, we built a relationship with her over a few days, and we got a tissue diagnosis to prove that she had cancer. We were able to tell her in a controlled environment, a quiet room, with her husband there holding her hand, and with certainty.

After reviewing her CT scan results with her, I paused again. I’d been holding her hand too. She let go of my hand and her husband’s hand to blow her nose. More quiet time. She looked at her husband, who was looking back at her. “I’m sorry,” she said. “That’s ok,” he whispered.

I think I’ll always remember that. “I’m sorry.” I’m sorry for getting cancer. I’m sorry that you’re sitting here, trying to recover from major surgery and your own cancer diagnosis, and I can’t support you through it like I’d hoped. I’m sorry that instead you’re being asked to carry an additional emotional burden. In fact, you are being asked to support me. I’m sorry I’m not going to be around forever. I’m sorry that you’re going to lose me. I’m sorry that I’m going to go.

It’s amazing how much two words can convey.

I didn’t cry. I held it together. When I felt they were ready to hear more, I continued.

“Since the test we did already can’t tell us what the source of your cancer is, we’re planning to do a different test on Monday.” I explained the test and what we hoped to learn from it. “Once we know what the primary source of your cancer is, we can send you home and you will follow-up with oncology as an outpatient. They will be the experts in treating you. Based on whatever the source of this cancer is, they’ll be the ones to advise you on treatment strategies and they’ll work with you to balance aggressiveness with quality of life.”

Now I was struggling. I had to somehow tell them that it was very very likely that this cancer was going to kill her, that her treatment would not be curative. I honestly can’t remember what I said. I don’t think I was clear enough about it. Eventually my resident chimed in: “We are not the experts on treating cancers, but we think that it’s very likely that her cancer treatment will not be for a cure. It will be to increase her quality of life and to keep her alive as long we can do so reasonably.” They nodded.

I think we must have said a few more things but they were inconsequential and I can’t remember them. We asked them if they had questions, but they didn’t. I reassured them that we’d be around all day and much of the weekend as we were on call. When they did have questions, we would do our best to answer them. My resident added “We’re going to leave you two here together for about 25 minutes so you can talk. After that we have to take Ms. P back to her room or the nurses are going to come after us.” They nodded again. We left.

I had 10 minutes to get to my lunch lecture. I hadn’t cried yet but I had a gigantic knot in my chest and my nose was running. There were huge cookies and a diet cherry coke among the drinks available at lunch. I love diet cherry coke and they never offer it. It made me smile. I took it and a cookie (and a sandwich) and sat down next to my classmate, Nadia.

“I saw the diet cherry coke and thought of you!” Nadia said. “How’s your day?!” “Yeah, I really needed the diet cherry coke today. God must be looking out for me. My day is horrible. I just told my patient she has cancer,” I responded. “Oh no! Are you ok?” she asked. “No, I’m not ok,” I said. She hugged me. I leaned on her shoulder and shuddered as a short sob came out. My eyes teared up. Still, I stopped myself. Nadia looked at me and said “If it’s any consolation, if I had to hear that news, I’d want to hear it from someone like you.” That did make me feel better and I was able to get a grip, if barely.

After lecture was preceptor group with one attending and 5 students. Our attending, Chad Whelan, always asks us how our week is going. I took the opportunity to talk about what had happened and he went over how to deliver bad news. My preceptor and classmates congratulated me on having done this. Two hours later, I was done so I went back to the floor. I had to go visit Ms. P. I found her back in her own room talking on her cell phone, looking *tired* but like she was getting good support from friends via the phone. She looked up and put the phone down for a second. I sat down. “I just wanted to come see how you’re doing,” I said. “Oh,” she replied. “I’m feeling….upset.” She looked at me, frankly sad. “Yeah, I can understand that. That’s probably better than feeling nothing at all, though.” She agreed. “I don’t have any new news for you. I just wanted to come see how you’re doing and let you know that I’m thinking about you all the time.” I got up. I gave her a hug. “Thank you,” she managed. I left her to talk on the phone and walked home.

Evan was there when I got home. He already knew what I’d done that day and he just waited for me to get my white coat off, put down my cell phone, and take off my shoes. He was sitting on the couch, studying. I crawled into his lap and he patted my head. I started to cry. Just a little at first, but then full blown sobs. “It was horrible,” I said. And I recounted to him how Ms. P had said “I’m sorry” to her husband. When I finally had cried myself out, we looked at each other. “Don’t get cancer,” I said to him. He agreed.

I’ve been slowly recovering from this experience ever since. My dear friends had to hear me talk about it before it happened, because I dreaded it. And now they’ve had to hear me talk about it since it happened, because it’s been totally upsetting. Its only been two days since this happened and I can finally write about it. I have the day off but I have to go over to the hospital to do a complete neuro & musculoskeletal exam on a different patient so I’m going to stop by Ms. P’s room to check on her.

Sometime late Friday evening the hospital administration managed to put Ms. P and her husband into the same room. My resident had been trying to make this happen ever since Ms. P was admitted to our service. I walked into their room on Saturday morning during rounds and they smiled at me. There they sat, each one in their own hospital bed with their own IV pole. Now their friends can come visit them both at once. They had been playing board games together. “Hey, they got you two together!” I observed. “That’s great.” They nodded in agreement. I turned to Ms. P. “The only problem with this is that now you can’t have any flowers in your room because he’s allergic.” Ms. P laughed and said “I know, we sent them home with our friends who came to visit and they were very happy to have them.” “Well, they were beautiful. And they smelled great. But having you two together is definitely better.” “Yes. Yes it is,” she agreed.

Disclaimer: My patient’s name has absolutely no P’s in it. I’m just calling her that to have something to call her.

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