One common question that faces quite a few candidates is how to deliver bad news to the patient.

One such case could be the commonest type of cancer, which is lung cancer. Imagine that you have to go and meet the patient and break the news to the patient that the   cancer is incurable and the patient cannot get chemotherapy and the patient is only fit for palliative therapy.

Most patient in the United States come and sit in a doctor’s office or in a examination room where the doctor would then enter after examining his previous patient and would go in and shake this patient's hand with the patient and say something like

Doctor: “Hello, Mr. Jones, good to see you again, how are you doing these days.”

Patient: I am fine doctor

How is the coughing.

It is bearable but still bothers me

Have you had any problems after the biopsy that was done for your lung.

No not really. Did the results come in?

We do have the results of your biopsy at this point in time. Unfortunately, I do not have good news to give you. The pathology report shows that there is cancer involved. The other tests that we have done have shown that it has gone to quite an advanced stage. We have looked at the other tests as well, with the possibility of doing something for it to either slow it down or cure it but that does not seem to be the case at this point in time.

Is it that bad.

It is not proper on my part to say that it is really bad but from prior experience with such cases, research shows that it is best not to do any invasive procedures unless compelled by some symptoms. I understand that this is a rough time and rough news that I have to give you, but during these tough times, I want you to know that I will always be there for you.

Am I going to be in pain Doc?

It is possible that pain may start but to me it will be a priority to make sure that your comfort is well taken care of. Also with news like this, I am sure that things come to your mind. There must be questions in your mind. There may be fears or concerns in your mind. It is best that we address them together so that whatever apprehension this situation will create can at least be lessened to some degree. I do have a copy of your biopsy report here which I would like you also to have. I am also going to put together the results of the tests we have done for you to keep and refer to anytime you wish to. Many a times a person wants to look up things for himself or herself. I am all for that move. One thing I do not want you to fall prey to is people trying to sell you something that may not be of any utility but vendors may be just wanting into make a quick buck out of you. There is another service available to you it is called the hospice service, I am sure you are aware of it. They have a very nice set up to help a person live comfortably while they are doing okay or even they are not doing okay to make sure that most of their needs are well taken care of. They are not stingy with things like oxygen if you are short of breath or painkillers if you are in pain or something for constipation or other symptoms that you may have. I am going to write you referrals so that somebody from the hospice house can come and meet you or you can go and meet them. As far as the time remaining that you might be concerned about, it is just so unpredictable that we physicians do not like to take a guess at how much time one might have. We do give averages out to patient. You may live longer than the average or less. At this point, I would say averages for this type of stage would mean anywhere from a months to 2 or 3 years.

Principles of handling terminal diagnosis situations.

Since we are at a stage where it is advisable that

1. We do not try any chemotherapy or radiation or surgery in this whole scenario, mention this to the patient and there are few key points that one must keep in mind.

2. You yourself should express that you feel bad giving the diagnosis out.

3. Making sure that you do not say that the diagnosis is horrible or diagnosis is deadly or such dramatically negative words but instead use terms which indicate that the diagnosis not good or not a very pleasant one or not a diagnosis that you would like to give a person. A method like this helps avoid the alarm that an extreme negative word would create.

4. The patient must know that you are there for the patient all the time and you will keep him comfortable.

5. You must offer the patient services of the hospice which is a specifically created organization to help a patient during such times when there is not a lot of time left in the patient’s life but there might be some discomforts approaching the patient.

6. You must also advise a patient to take care of their legal affairs and put them in order.  These include Power Of Attorney, Will, Insurance and financial matters.

7. Make a formal referral to a hospice organization unless the patient is completely against this.

8. There is something that I do prefer which is a quick follow up for the patient because patients like this have many questions. They go on the internet, they do some research, they find out other things and they would like to discuss it with somebody who they trust and most likely is going to be the family doctor or whosoever breaks the news to the patient about such a diagnosis.

9. Keep yourself open to be discussing anything the patient finds out that might be to the contrary of what the patient has understood from you.  Do  not feel offended as patients are not questioning your authority but are actually seeking your help.

10. And lastly if there are any resources that you can offer the patient like the cancer society or the heart and lung association, etc., etc. please offer those to the patient.

In our short discussion we also explained that the patient should be warned against these so called advertisements that they might receive on the internet or in their email etc., which says you know, cure for cancer etc. etc. or in a herbal food store somebody might have an anticancer, antioxidant and things like this which the patient might just unnecessarily spend their money on them without any known or proven benefit.

With the permission of the patient, keep the family informed. There is a new rule called HIPAA in the USA and compliance with this requires that you only discuss matters with those whom the patient has formally allowed.

A discussion with the patient and the family for DNR status must be initiated. Allow patient time to decide this issue.

Always allow a  patient a second opinion.