One of the most challenging tasks for patient-advocates is to deliver bad news about impending death to a family. It is never an easy task, even for the most seasoned of healthcare professionals.

Dr Sudhir Bhatia, a senior internal medicine resident receives the lung biopsy results for Tushveen Khanna, an attractive 26-year-old patient, who has her whole life ahead of her and is busy shopping for her wedding planned for next month. Khanna’s test results show she has an advanced stage of lung cancer.

According to standard medical protocol, Dr Bhatia orders a PET scan and requests a consultation with a cancer specialist. An hour later, a nurse phones to inform him that the distraught patient has refused to undergo the PET scan until she sees her doctor. It suddenly strikes Dr Bhatia that no one from his team has discussed the biopsy results with the young woman and prepared her for what lies ahead. Sometimes, doctors are so focussed on “treating” abnormal test results that they forget about the patient.

When he finally gets to see her that evening, Dr Bhatia finds her sleeping, with a young man keeping a watchful vigil over her. Dr Bhatia gently wakes up the patient. “Hello, Ms. Khanna. I’m sorry to wake you, but I need to speak with you about your biopsy results. Unfortunately, it’s positive. I’m afraid it looks like you have lung cancer. We need to run another check on you, a PET scan, which would determine the spread of the cancer, but the nurse told me that you have refused it. Meanwhile, I’ve asked Dr Mukhesh Batra, who is a specialist in lung cancer to also come and examine you. Do you have any questions?”

The girl looks at him wide-eyed and scared. Her fiancé is equally bewildered. For a brief moment, they are both silent. Then finally, he speaks up, “I thought she had pneumonia. Now all of a sudden she has cancer?”

Before Dr Bhatia can respond, the poor girl bursts into tears and exclaims, “I don’t want to get any more tests done! I just want to go home!” “She is right. We just want a discharge,” says the young man.

Their reaction catches Dr Bhatia off guard. Didn’t the news sink in? Didn’t the girl and her fiancé understand Rabow MW, McPhee SJ what he has just told them about the biopsy results? Suddenly he is unsure what to do next. He has three more patients to see before he can leave for dinner and home. He tries to calm down the young girl and persuades her to get the test done, but she adamantly digs her heels in. Dr Bhatia suddenly feels helpless and cannot understand why the patient is being so uncooperative. He tries to hide his frustration as he decides to leave to find the oncologist and get him to talk to his distraught patient.

No marks for guessing where things went wrong in the first place.

Is it necessary to tell the patient?

The answer is yes.

Fifty years ago, it was standard practice in India to withhold the diagnosis of advanced cancer from a patient. Often the relatives themselves pleaded with the doctor to hide the truth from the patient, because they were worried that the patient would not be able to digest the “shock.”

However, mindsets have now matured. Studies have shown that patients do want to have the correct diagnosis, even if it is bad news, because they don’t want doctors and family members to play games with them. It is important that patients are given all the medical facts, especially about their own health. They have a right to know, so that they can make informed choices about their medical, personal and legal matters.

Undoubtedly, breaking bad news to critically-ill patients can be a challenging task but for the healthcare professional, it’s an occupational hazard that comes with the territory. For a young and inexperienced physician, it can be particularly stressful, especially when the patient, as in this case, is young and there are limited prospects for recovery.

This is where a patient advocate can help. She can help all the stakeholders - the doctor, the patient and the family - in managing the medical crisis by providing truthful and accurate information about possible health outcomes, without deflating the patient’s hopes for recovery. Indeed, breaking bad news kindly and managing a patient’s expectations is one of the most important tasks that a patient advocate can discharge. The advocate has to be wise like the Roman God, Janus, and be able to see both the doctor’s perspective, as well as the patient’s, so they can both talk with each other.

Stick to the medical facts

Patient advocates might find these tips on how to soften the blow useful...Start from what the patient understands. Begin at his level and use words that are devoid of medical jargon, so that a lay person can understand them easily.

Responding to the patient’s emotional reactions is one of the most challenging tasks for an advocate. The patients’ reactions may swing wildly from silence to disbelief, crying, denial, shock, grief or plain anger. She may use you as a punching bag, so be prepared to act as an outlet for outbursts.

An empathic response calls for four kinds of interventions:

Communication strategies

Here are a few communication techniques that you, as an advocate, can use with critically-ill patients:

All said and done, bad news must be delivered after carefully assessing a patient’s level of understanding, compliance, and wishes for disclosure. Speak slowly so that the patient and her family understand. Choose your words thoughtfully and try to avoid causing any unnecessary mental anguish and anxiety.

Last but not the least, a patient advocate can help to reassure the patient that her doctor will abide by three solemn commitments to her critically-ill patient: