Ethics Commentary: Communication and Breaking Bad News

July 2, 2009

Commentary on Dr. Cox’s Tales of Survival by Antonella Surbone MD PhD FACP, Ethics Editor

Commenting on Dr. Cox’s honest heartfelt piece is not an easy task and even less so for me, as Ethics Editor. Why? Because before being a trained, published bioethicist, I’m a physician too. I’ve been through medical training and Fellowship in oncology in Italy and in the US: everywhere I have experienced the same doubts and felt the same anguish that Dr. Cox powerfully describes. During my internship, I still remember calculating over and over the dose of electrolytes needed by patients in renal failure for fear of making a mistake, drawing my first ABGs without ever having done it before or being taught how to do it, trying to halt with my hands a major epistaxis in an old man with metastatic prostate cancer and DIC while waiting for the blood bank to send up what I had requested. I felt almost overwhelmed by fear, yet even more powerful was the desire to ease the suffering of other fellow human beings. I shall never forget when, during my first night on-call at the NCI in Milano, three patients died. I was young; they were all younger than me. And I was the one who had to tell their families. In Italy we do not always request autopsies, but in one case it was important to understand whether an experimental drug had contributed to the patient’s death. His family understood the need for the autopsy, yet, as in the case of Dr. Cox, they refused it. It was simply “too much.”

I too asked myself if it would ever get easier, if I would ever stop feeling as though I was intruding on one of the most sacred moments in family life, when someone loved and treasured closes her eyes forever. In my over 25 years of oncology practice, it never got easier, nor did I get more used to my patients’ death or felt less intensity when telling their loved ones. Something did change, though: with increasing clinical experience, I have been able to establish deeper connections with my patients and their families, never, I hope, overstepping the boundaries of the patient-doctor relationship or losing sight of my objective clinical judgement. On the contrary, by learning how to be closer to my patients and their families, I also became a better physician. I acquired diagnostic and therapeutic skills that only empathy makes possible, since to be a good doctor one needs to listen to patients and to establish with them a strong reciprocal trust.

Empathy is part of the healing power of the therapeutic relationship between patients and doctors. (1) Empathy, however, can only be expressed fully when physicians have acquired a higher enough level of clinical expertise that allows them to get closer to their patients without being afraid that intimacy could cloud their clinical judgement. At a certain point, defined by our degree of maturity as physicians and as persons, we no longer require distance in order to function effectively. From that point on, then, it becomes “easier” to be close to our patients and also to tell relatives that their son, husband or mom died, and even to ask for an autopsy.

In a piece featured in the New York Times of March 12th 2009, Dr Pauline Chen discusses the feeling of abandonment that many patients and families experience at the end of life. (2) She cites the results of a study from Seattle that examined feelings of abandonment at the end of life that examined this experience from the perspective of patients, caregivers, nurses and physicians, recently published in Archives of Internal Medicine. (3) The study found disparities in perception between doctors and patients. Doctors were aware that dying patients might feel abandoned might feel abandoned, yet this awareness did not, apparently, translate into more effective and empathic approaches to their patients, as both patients and caregivers still felt abandoned by doctors at these times. The authors suggest that physicians should be more aware of the importance of non-abandonment and of patients’ and caregivers’ need for closure. They should be more open in acknowledging the approaching of death with the patient, and calling the family or sending a condolence note after death. Yet, as the leading author stated, physicians are often unaware of the “tremendous therapeutic value of their presence, even on the phone” or “are worried about how they will manage their emotions, so they keep things at arm’s length.” (2) Moreover, physicians still lack proper teaching and training in communication skills. Part of improving these skills involves learning about one’s own emotional responses to patients, about how comfortable or uncomfortable one is with the feeling of personal failure when losing a patient, and about how open one is to seeing that it is possible to help patients even when you can no longer cure or save them.

This brings me to my final comment. I found it very troublesome that Dr. Cox writes that “despite all the med school small group sessions about ‘breaking bad news’ I had no idea what to say.” Clearly, the communication teaching was not effective or , at least, not sufficiently so. A recent article in the Journal of Clinical Oncology pointed to the importance of training the trainees. (4) Only if this is done successfully can we expect that medical students, and medical doctors who attend communication skill workshops or courses, will be actually will learn how to communicate with their patients, especially when breaking bad news and at the end of life.

Ancient Greek philosophers tended to believe that “virtue cannot be taught”, yet they dedicated their lives to find the most effective methods to teach virtue. Being good communicators is, in part, an innate quality that not all of us have: still, communication skills can and should be taught. We, as senior physicians and as teaching institutions, have the responsibility to do so, by acting as role models and by providing effective education and training in communication in the clinical setting.

1. Spiro HM. What is Empathy and Can it be Taught? in Empathy and the Practice of Medicine. New Haven and London: Yale University Press,1993.
2. Chen P. When patients feel abandoned by doctors. The New York Times, March 12th 2009.
3. Back Al, Young JP, McCown E et al. Abandonment at the end of life from patients, caregivers, nurses and physicians perspective. Loss of continuity and lack of closure. Arch Intern Med 2009; 169:474-479.
4. Back AL, Arnold RM, Baile WF et al. Faculty development to change the paradigm of communication skills teaching in oncology. J Clin Oncol 2009; 27: 1137-1141.