Traditionally, grave medical news is shared in person; we're now having to do so virtually. During such conversations, try to infuse as much warmth and compassion as possible.
I was reviewing a young hospital patient in full PPE, when a colleague in the room held our tablet computer in front of me.
“It’s mum,” she said.
It was the patient’s mother, from her phone, via our video messaging app.
“Hello,” I said.
The mother was a bit taken aback as it was quite early in the morning and she had perhaps only expected the healthcare assistant plus her son in the hospital room, but was now faced with speaking with the palliative care consultant. She apologized for being in bed, I told her not to worry, and we then went on to discuss the latest news in her son’s care, with him present on screen next to me. Some of the news wasn’t good but needed to be discussed.
“You’re on mute!” – The new normal in medical conversations
How things have changed in just six months. When possible, we now offer video and phone consultations to all our patients and their families. Many are self-isolating at home, and others are rightly reticent about coming to the hospital or clinic in-person. Video messaging has become an expected new way of communicating, without the luxury of detailed planning and consideration that we sometimes afford new developments in medicine.
Some patients have been enthusiastic and grateful (“I prefer videoing you from home, doctor. It meant I didn’t have to walk through your hospital’s outpatient department with tears streaming down my face.”) Others have found it more of a challenge (“I’ve been asked to download Google Chrome, doctor, so I can get your video call, but am embarrassed to admit that I don’t know what that is. I don’t know if I can handle this, can I see you in your real clinic?”)
When COVID-19 hit Lombardy in Italy hard, I got in touch with Italian palliative care physicians who urged me to ensure that patients had access to a laptop, tablet, or smartphone when they came into hospital, due to visiting restrictions. They said the loneliness and isolation on their wards was hard to witness, and many gave their phones to patients so that they could contact a familiar face at home.
Breaking bad news
What I and some of my colleagues were less prepared for was the advent of breaking bad news by video or phone. Some discussions have involved addressing the topics of worsening disease that is no longer curable with either patients or their caregivers at home. Sometimes it involves discussing the concept of resuscitation and a person’s views on potential CPR if they became seriously unwell. The bad news scenarios involve people with and without COVID-19, because all the other serious illnesses have of course not gone away. Here are some tips that I’ve accumulated over the last months, but the list is not exhaustive and can be expanded on.
9 tips for breaking bad news via video or phone:
1. Prepare before connecting with your patient.
Make sure you’re in a quiet setting before you begin. Consider warning colleagues nearby that you are about to have a serious conversation. Take a break for water, food, or the restroom before a potentially long call.
2. Review your prior notes.
Regarding the bad news, how much does the person suspect already?
3. Have suggestions for what to do next.
Further tests, investigations, and both non-pharmacological and pharmacological options. Think about follow-up, is it needed quite soon to clarify questions?
If I’ve had multiple difficult phone or video conversations in a short time, I need to take a break before going into the next one. It’s important to know your own limitations and take a rest, even if it’s just a few minutes.
4. Double-check that it’s ok or safe for your patient to talk right now.
If needed, reschedule to a better time for your patient.
5. Warn your patient what’s coming.
I nearly always preface that I have some difficult news. I might say something like, “I’m sorry, but there’s some news that isn’t good.” If someone asks me to stop there, I do so, and offer to reschedule. They aren’t ready yet and need to speak later. They need time to prepare.
6. Share the news with compassion.
Give a summary of what you know with compassion and without small talk. I once heard a doctor talk about the weather before giving bad news, which is just no good. If you’ve been given permission to proceed, do so. What I do sometimes do for patients whom I think may take the news badly is intersperse questions checking whether they were expecting this news and whether they need a break or wish me to stop. I may say, “Is this what you were fearing?”
I often find that people have already suspected and thought about the different bad news scenarios. “Yes, doctor, this is what I was fearing all long.”
7. Close the conversation.
You can ask, “Shall we make a plan together? Are there people you need to tell? Is there someone else you’d like me to talk with for you? Who is there to support you?”
I often see my patient again soon if there aren’t many people to offer support.
8. Ask your patient to summarize.
I also try to ask the person to summarize a bit about what we talked about. It allows them to ask questions. Sometimes, the white noise that breaks into our brains after a sentence like, “Your cancer has spread,” or, “Your husband has just died,” is so intense that it can be hard to process.
9. Remind your patient how to get in touch.
In closing, I say good-bye, how to get in touch at the hospital, and remind them of the follow-up steps. I try to find a way of expressing that we know how difficult this all is, and I make reference to the fact that I much prefer seeing people face-to-face, rather than video. If needed, I will also highlight support agencies and charities, particularly local ones, that can provide a listening ear.
A video or phone conversation can offer benefits to some patients, including not having to worry about hospital transport, long waits to see a clinician, and being able to speak to experts from the comfort of their own home. Perhaps the biggest drawback is that video conversations may miss the subtle nuances like body language and comforting touch that make all the difference in real life, face-to-face discussions. We have much to learn from telehealth consultations, but the most important thing to remember is to infuse as much of our own humanity as possible.