(continued from previous page)
“I left feeling honored to have been there, and incredibly grateful for my life. It just put things into perspective,” she said, adding that her experience prompted an extemporaneous visit to see her parents that weekend. “I was surprised at how deeply the experience affected me. I don’t think I’ll ever forget it actually.”
Death — specifically how physicians should break bad news, process the information themselves, and relate to dying patients — is not a particular class at VUSM, but is instead woven throughout the curriculum and into teaching rounds by faculty members who believe that students should learn early that death and loss are an everyday part of the physician experience. Lessons learned early on can help the physicians-in-training be better at both breaking bad news to patients and their families and caring for a dying patient. The lessons can also help them learn how losing a patient will affect them, and what they can do to emotionally protect themselves.
“We in the hospice profession have accepted death as a natural extension of life,” Henderson said. “Just like birth, it’s commonplace. We grieve, of course, but in some cases we rejoice because suffering has ended,” Henderson said.
When she explains what she does to others, they often ask if it’s depressing, she said. “I tell them it’s not. It’s very rewarding,” she said, recalling a conversation with a Vanderbilt third-year student who had witnessed a dying patient at Alive Hospice. “We left the room to discuss the patient’s case. I could tell he (the medical student) was taken aback by what we just saw. I was getting ready to go on with the medical details, but I saw his face, and we stopped and talked about it and how we do this work. I told him if we measure ourselves as physicians as death being failure, we’d always be unhappy and never measure up, because mortality is 100 percent. Death is not a failure because it’s the ultimate end for all of us.”
Henderson, who says she wasn’t exposed to death in a medical setting until her geriatrics fellowship at Vanderbilt under James Powers, M.D., tells students it is OK to be emotional. “Just like the science we learn, this will be a learned process, too. How much emotion depends on the physician, the circumstance, the day,” she says. “I can’t think of an emotion that isn’t acceptable. All of my physician partners have cried with families. We have some long-term patients who have become part of our family here. You may connect to someone because of their age or because of similar life experiences. And sometimes you don’t even know why it touches you, but if it does, it’s better to let that emotion show. Families are having those emotions too and they appreciate knowing that grieving is OK.”
Breaking bad news
Frank Boehm, M.D., admits he’s emotional. He has felt things intensely since he was a child, he says. In his book, “Doctors Cry Too,” he recalls an experience as a 26-year-old intern in obstetrics that has stayed with him throughout his career. During an emergency Caesarean section, both the mother and child died. As Boehm accompanied the woman’s attending physician down the hall to deliver the bad news to the woman’s husband and mother, he felt a lump forming in his throat. He no longer remembers what the physician said to the family, but he clearly remembers the “stunned expressions and chaotic disbelief” in their eyes as the dry-eyed attending delivered the bad news.
Although he tried not to, Boehm began to cry, and the woman’s mother put her arm around him and thanked him for caring, reassuring him that the medical team had done all they could. “She had just lost her daughter and grandchild, and she was comforting me,” Boehm recalls. He left the waiting room and retreated to the doctor’s lounge where he was surprised to hear muffled sobbing — the attending physician had been able to hold back his tears around the family, but freely let go when alone.
“It occurred to me that physicians show their grief in different ways, but I believe patients and their families really care how we feel about what happens to them,” he said.
Boehm frequently has a “teaching moment” with residents by offering tips on how to break bad news to patients and their families. It’s not a formal talk or lecture, but instead a note card he keeps in his pocket. “I’m not sure you can teach compassion, but at least you can teach showing compassion.”
The tips:
- Prepare. Before you deliver bad news, select a private area. Turn your beeper and phone off. “Nothing is more important at this time than the discussion you are about to have.”
- Watch your body language. Boehm suggests breaking bad news sitting on the edge of the bed and looking the patient in the eye, or sitting down, facing a family, leaning forward making eye contact.
- Once the bad news has been broken, don’t try to comfort with words. “You won’t be able to do it,” Boehm said. “The only thing that really works is ‘I’m so very sorry.’ Saying things like ‘I know how you feel’ doesn’t work, because you don’t know how they feel even if you’ve had a loss.”
- It’s OK to touch patients, to give them a hug, to put your arm around them. “They want to know that you care what is happening to them.”
- Use “speak back.” Ask the patient, “What did you hear me say?” not “Do you have questions?” Frequently patients stop listening after they hear statements like “You have cancer of the ovary. It’s spread to the lungs.”
- Finally, try to leave patients and their families with hope. Not hope for a cure, necessarily, but with the reassurance “I’ll be there for you.”
<<back continued>> |
 |
|
|
