The four rules
by Biren Kamdar, M.D., PGYIII

When I first started medical school, I was aware that death would inevitably be a part of my day-to-day profession, but was clueless about physicians’ interactions with real-life dying patients. As a third-year student caring for patients on the wards, critical end-of-life discussions and the death of patients seemed to occur behind the scenes while I attended mandatory medical student lectures or after I had already gone home.

The reality of what I would face as a physician became more evident during a risk management course during my final year of medical school. This lecture series provided us an overview of medical pitfalls including medication error, improper documentation, and malpractice litigation. Interestingly, I learned that practitioners with the most effective communication skills were sued the least — not necessarily those who graduated at the top of their class or with the strongest clinical acumen. This lesson was especially true in the setting of death or when breaking bad news, where the rules were simple: 1) choose a quiet location without disturbances — i.e. close the door and turn off your pager, 2) be a straight shooter — i.e. deliver the news honestly and without vagaries, 3) use simple phraseology — i.e. say “he is dead” rather than “he is not with us anymore,” which can be easily misinterpreted, and 4) pause early and often to allow all news delivered to “sink in.”

These four simple rules have guided me through my residency, not just in breaking bad news, but in almost all of my doctor-patient interactions. As an overworked house officer, it seems that the most grave, urgent situations find me at the most inopportune times. Regardless of the circumstance or outcome, these rules serve as a simple mantra and to this date have not let me down.

One such incident occurred soon after completing my internship, as a new resident rotating through the Medical Intensive Care Unit at the Nashville VA Hospital. A young veteran in his early 40s with newly diagnosed acute promyelocytic leukemia, a form of bone marrow cancer, was admitted to the ICU with signs and symptoms of shock. Although the patient was cheery and conversant with staff on arrival, he quickly developed multi-organ failure and slipped into a coma, his death imminent despite maximal medical therapy. His family members were in the hall outside the ICU, waiting for an update from his doctor — me. They had never met me, and worse, had no idea what fate just befell this person whom they loved so much.

As my intern scampered to place orders, recheck lab results, and prepare for the inevitable, I was mentally preparing myself to talk with his family. “Remember the four rules,” I thought. I found a large, smiling group including his parents, two sisters, and brother eagerly awaiting my arrival. I introduced myself and settled into a quiet spot in the waiting room, telling them point blank that our patient had taken an unexpected turn for the worse and would surely die barring a miraculous turnaround. After processing the shocking news, his mother simply asked, “Can we see him while he is still alive?” “Of course,” I replied, promising to summon them in 15 minutes, just as soon as his room was tidied up by the nursing staff.

To my dismay, the patient lost a pulse and flat-lined the moment I returned to the ICU. In some futile clinical situations it would have been appropriate to let the patient pass peacefully, but since he was relatively young and previously healthy, he deserved every possible chance of survival. Moreover, I could not let his family down. We performed several cycles of CPR for 30 minutes, but he never regained a pulse. He expired less than two hours after his arrival in the ICU. His family would never be able to say their goodbyes.

I have had to break bad news several times, but never to the same people twice in a thirty minute time span. My head was swimming, but I once again retreated to my four rules. I took a deep breath and walked toward the waiting room. There his parents stood, composed, eagerly awaiting my permission to see their son. Instead of taking the family to the chaos of the ICU, I took them to the nearest conference room, my hands shaking on the doorknob, thankful that it was unlocked. The family knew something was wrong, but I fought to maintain my composure. After sitting them down I told them in my most earnest demeanor that their loved one had arrested minutes after my previous conversation with them. Despite our efforts to revive him, we could not save him. He was dead.

To no surprise, the patient’s sisters fell to the ground, crying loudly in anguish, holding each other. The reaction of his parents surprised me. Using his cane, the patient’s father pulled himself up, walked over to me, and held out his hand. “Thank you for everything you did,” he said, shaking my hand. “You fought hard for our son. This must be very hard for you, too, and we appreciate your honesty.” I was shocked and impressed by this man’s strength. After hearing such tragic news about his son, he was thanking me? My overwhelming feelings of guilt and powerlessness were overcome by a sense of relief. At that point, everything and nothing made perfect sense.

I would be lying if I said I have not dealt with tragedy since that fateful day in the VA MICU — after all, it is a part of the job. Regardless of the scenario, I continue to have meaningful experiences when approaching these situations with compassion, strength, and, most importantly, honesty. Incidentally, after I complete my residency I will specialize in pulmonary and critical care medicine, a field where morbidity and mortality is the norm. While I look forward to using my training to save lives, I feel comfortable being the bearer of bad news in times where families are seeking compassion the most. To my amazement, I find that the most gracious patients and families are those dealing with bad news and loss. In the end, it is not the type of news that is delivered, but how it is delivered and by whom. As long as I stick to the four rules, the result is always a positive one. VM