I Can’t Talk to You With a Gun in My Face

Rebecca Bechhold, MD

How many times have you been killed for being the messenger with the bad news? You can often tell who is going to be angry when the CT scan shows recurrent disease. It is one of many things that are so stressful about being an oncologist. Let’s be honest, over the course of our career we give a lot of bad news.

It is wise to be honest with patients and families from the first meeting. Don’t let them have unreasonable expectations, always be straightforward, and communicate clearly and compassionately. But sometimes you know going in that someone in the room is going to be furious with you. They will hear only a fraction of what you say, and will make their anger and disappointment painfully obvious-not to mention their declaration that you are incompetent.

I saw a young woman in her 30s, with two small children, who presented with stage IV colon cancer. Her liver was essentially replaced with tumor. Her mother accosted me at first sight with the statement, “We don’t want to hear anything negative.” Her family took her to many doctors in the city. You can guess the outcome. Incredibly sad. But the patient’s mother did not help her by setting up capricious guidelines for the consultation. No one could meet her needs, and I think this young woman could have had excellent care, albeit for an ultimately terminal illness. I completely understand her mother’s agony and desperate plea, but she tied the hands of every doctor and prevented her daughter from having an open discussion. Maybe she wanted to set some realistic treatment goals. I doubt anyone had the opportunity to hear what was important to her in her disease course.

Another patient had a gastrointestinal cancer that we were able to treat with neoadjuvant therapy and surgery. He was high risk for recurrence, but did well for a period. He worked every day, enjoyed a lot of time with his family. He called one day with a symptom that made me very suspicious that he had recurred, but after a full evaluation, I could find nothing. Still suspicious, I called to tell the patient and his wife the test results. Well, they were ecstatic, which made me very uncomfortable. I felt in my gut that there was disease lurking; we just had not found it yet. The wife sent a lovely note and a massive flower arrangement. If she could have hoisted me onto her shoulders and trotted me around the city, she would have. She proclaimed my brilliance to one and all. Six months later, he had obvious disease and we had to restart treatment. My clay feet were shattered. As time went on, the patient became increasingly debilitated from drug toxicity and progression of disease. After making a home visit and seeing the patient almost completely incapacitated, I finally said I could not continue to treat him. The wife found another oncologist who would. From one of the med onc’s notes, copied to me, I could tell that he did not want to continue treatment either, but felt intimidated by the fury of the patient's wife. She never spoke to me again.

Though I realize she was driven by her intense love for her husband, I do not think he had a good death, and he suffered needlessly. This is a scenario that happens every day. Well-meaning family or friends bully the doctor to do things that are not in the patient’s best interest and certainly do not make them live longer or better.

We have been schooled in how to handle angry or demanding patients or family: be calm, don’t take it personally, let them talk, restate their conversation to make sure they feel understood and valued. But at some point, the truth will come to bear. How do we help people face the worst thing that could befall them and maintain dignity and sense of worth? Happy patients and good outcomes are so much easier.

But we didn’t sign up for that, now did we?

For the handful of visibly shaken, mad-as-hell patients, there are scores of people who appreciate our best efforts, even when the results are not what we hope and work for. We cherish each card, note, thank-you, and kind touch from grateful patients. It is what lifts our spirits, and gives us the energy to go on to the next room, the next case, and hopefully, the next victory.