How can GPs best deliver bad news?

It has been 25 years, but Dr Wendy Burton can still see her patient’s face.
 
The woman was 22 weeks pregnant with her first child and everything was going ‘swimmingly’.
 
Then the worst happened.
 
‘Her baby had stopped moving,’ Dr Burton told newsGP.
 
‘I had seen her on the Friday before, we got her up on the couch and listened and boom, boom, boom, the heart beat was there. This time I got her up on the couch and we could not find the heartbeat.’
 
Dr Burton sent the patient for an emergency ultrasound.
 
‘[Afterwards] she came back straight to see me. They rang me while she was on the way [to say] the baby had died,” Dr Burton said. ‘She was distraught. It was devastating.

‘That one would be 25 years ago and I can still see her face.’
 
Giving bad news is part of the job for doctors. But does it leave its mark?
 
‘You can’t be human and not be impacted,’ Dr Burton said.
 
‘It’s part of the journey we do as general practitioners – preconception to post-cremation. So you are part of the best and part of the worst part of people’s lives.’
 
Dr Burton, the Chair of the RACGP Antenatal/Postnatal Care Specific Interests network, has been practising as a GP for 31 years. She can’t remember the first time she delivered bad news, but she remembers feeling ‘outraged’ at the lack of training provided at her medical school on the issue.
 
‘Back then, we weren’t taught how to deliver bad news, nor how to protect ourselves from the emotional fallout,’ she said.
 
‘In my university course – this is of course more than 30 years ago now – there’d only been one lecture on how to break bad news.’
 
So how can GPs best deliver bad news?
 
RACGP’s Education Strategy Senior Advisor Dr Ronald McCoy said the ability to break bad news is considered a key communication skill for GPs.
 
‘It’s part of the curriculum,’ Dr McCoy told newsGP. ‘[W]e spend a lot of time in training and teaching people. It’s a really good general indicator of a doctor’s communication skills.
 
‘It’s never easy even [for] the best trained doctor, because it is bad news and there is no sugar coating it.’
 
And Dr McCoy would know.
 
In the 1990s he was involved in the management of serious blood-borne virus infections.
 
‘I personally told probably about 500 people they had hepatitis C,’ Dr McCoy said. ‘I fortunately had good training beforehand, so I knew exactly what to do. I was well prepared.’
 
Even so, it is easy to make mistakes.
 
‘Even with the best intentions because of the bad news, the patients can take it wrong,’ Dr McCoy said.

He advised controlling the environment to ensure there were no interruptions.
 
‘If you think that there might be bad news coming, it’s a good idea to get them to come with somebody,’ Dr McCoy said.
 
‘Find out physically what they are going to do when they leave the consultation room and who they are going with and who they are likely to talk to about the diagnosis.’
 
Dr McCoy has found it is important not to initially bombard the patient with information.
 
‘When people are given bad news … there is a shock, and they find it very hard to take in any new information,’ he said.
 
‘As a doctor, one of the things you want to do … [is] to tell them all the things you can do to help … but the patient can’t hear. So at that initial point it’s more about emotional support and reassuring [them that] something can be done.’
 
Dr McCoy said once the patient has settled down, the doctor can then discuss different options.
 
‘When people see their doctor, it’s about their health. They feel vulnerable. And the biggest fear is that people feel like they are going to be left alone and abandoned,’ he said.
 
‘If you demonstrate empathy you are tacitly saying to that person, we will work on this together, that we are prepared to work through this, you are not alone, there’s lots of people who can help you.’
 
A new study published in BMJ Open found that female health practitioners show more empathy than male doctors, but are also more prone to burnout.
 
Dr McCoy said doctors also need to have empathy for themselves, taking time to reflect on their own feelings, particularly after a difficult consult. 
 
‘Those patients who have good social supports cope better. In the same way, if you have a good peer support network and you talk about these things, it’s much better,’ he said.
 
‘The doctors who have problems are the ones working in solo isolated practices. Collegial support is in fact really important.’
 
Most patients that Associate Professor and GP Joel Rhee sees are more than 80 years old. He told newsGP that seeing patients through their end of life is challenging, but rewarding.
 
Associate Professor Rhee, Chair of the RACGP Cancer and Palliative Care Specific Interests network, said delivering bad news never gets easier, especially if the patient is quite upset about it.
 
‘Just because someone is a bit older doesn’t mean they are going to take the news any easier than someone who is younger,’ he said.
 
‘It’s not an easy conversation to have. It’s challenging, you do have to catch your breath. It’s not something you can do in five minutes or 10 minutes.’
 
Associated Professor Rhee said he often takes time to debrief with his spouse, Wendy, who is a rheumatologist.
 
‘So when it comes down to these difficult conversations … I discuss it with my wife and I will be able to get some reassurance that at the end of the day things are okay,’ he said.
 
‘Obviously it’s unfortunate for the patient, [but] that’s the world we live in where there is 100 per cent mortality and everybody dies. Bad things happen, but also good things happen as well.’ 
 
Associate Professor Rhee said most of his appointments are for a longer duration, allowing time and space to discuss any bad news.
 
But sometimes things do go wrong, and for patients the delivery of bad news becomes as much part of the trauma as the actual bad news.
 
In 2010, Melanie McKenzie was pregnant with her fourth child when she was told her baby only had a 50% chance of survival.
 
He had been diagnosed with congenital diaphragmatic hernia, a birth defect in which the diaphragm doesn’t form properly.


Even after eight years, Melanie McKenzie remembers the way the doctor delivered the bad news about her son’s diagnosis. 
 
‘When we were delivered the bad news, the doctor was quite aggressive and when I started to cry, he snapped at me and said “Are you listening to me?”’ she said.
 
‘Since [Harrison] died, it’s eight years on and … I live with that comment and that harshness.’
 
She said the doctors were ‘straightforward’ when they delivered the bad news.
 
‘They just put it out there; there was no tenderness, there was not a lot of compassion, it was just like, “This is what you’ve got. This is the statistics.” It was very clinical,’ Ms McKenzie said.
 
‘[Doctors] need to have compassion and empathy when they are delivering bad news. Not to be short and so clinical.’
 
Harrison only lived for 28 hours.
 
Grief-stricken, Ms McKenzie founded a not-for-profit organisation, Harrison’s Little Wings, to provide peer support and practical help to families who receive a serious or fatal diagnosis or have an extreme high-risk pregnancy.
 
‘From my own personal experience, it is very important that when doctors are delivering bad news the [patient] has the support system around them,’ she said.
 
‘Our mission is to take away the stresses of the family. We’ll provide practical services like house cleaning, yard maintenance. We will help advocate for them, we will go into the hospital if they require … we are happy to walk with the family.’
 
Dr Burton said being prepared helps doctors to better support patients.
 
‘You try to … get as much information, think about what is it they are going to want to know: “So who can I call? What resources can I pull up, and what’s the next part and how can I make it easier for them?”’
 
She said it is important to remember that the patient is the one most affected by the bad news.
 
‘Even though you wouldn’t be human not to feel some of the fallout, you can’t own it,’ Dr Burton said.
 
‘It’s not your grief, it it’s not your journey, it’s their journey. And you have to keep yourself safe in that role.
 
‘Personally, I go to the gym and I swim and that’s my emotional safety. I listen to music, I go to church, I sing. There’s all sorts of different ways to manage what is an important but often difficult and emotionally draining job.’

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