REFLECTION PAPER ON BREAKING THE BAD NEWS

Submitted by: Dr. Lady Aizahlyn I. Angod- First Year Resident

Our four years of medical education plus one year of internship taught us about
the basic knowledge and skills that a physician must possess. And just when I thought
that I was ready to venture into the real world after passing the board exams, I realized
that my medical education has not really prepared me for this daunting task of breaking
the bad news to my patients.  Let me share with you my personal experiences and
struggles as I started my journey as a doctor. 

When I was still an emergency room physician, everything was done in a fast-
paced manner, admitting one patient to the next, with only minimal interaction with my
patients and family members. At the end of a very exhausting ER duty, I would always
wonder what really happened to my patients at the ward. I had limited patient
interaction way back then. Few weeks later, I was hired as a hospitalist at MHARS
Medical Center and started doing rounds at the ARI-SARI ward at the height of the
pandemic. This is when I got the chance to interact with the patients and their family.
And this is when my dilemma started. How am I going to explain to the patient that
he/she tested positive for COVID-19 and the available treatments are still considered 
investigational drugs with no assurance of cure? How am I going to tell them in a tactful
and compassionate manner? 

When I had my rounds at the Neuro Ward, I encountered a lot of patients with
very poor prognosis, such as those suffering from Massive CVD Infarct, Bleed or
Multiple Brain Metastases. I would always feel pressured whenever the patient or the
family would ask me about the patient’s condition and prognosis during rounds. How
am I going to explain the patient’s prognosis?

And when I finally handled patients as a resident, the situation became more
challenging than ever. There were moments when I had to hold back my tears after
seeing the initial findings suggestive of malignancy, especially for the young and
breadwinner patients. There was even a time when I would convince my fellow
residents or my seniors to accompany me during the bedside round of a morbid patient
since I did not want to see him deteriorate and I absolutely have no idea how to further
explain the patient’s condition to the family. 
 I have to admit that I really struggled at the very beginning.  It is an unpleasant
task. I am fearful of the patient's or family's reaction to the news and I don’t know how
to deal with an intense emotional response. These experiences made me realize that
being a physician is not all about knowing all the latest guidelines or the technical
proficiency of patient management,   but it is also very important to have good
communication skills, especially in breaking the bad news to the family members. 

In line with this, I am truly grateful because Dr. Montolo gave us a lecture on how
to break the bad news in a compassionate and effective  manner. Communicating the
bad news is a two-way activity that requires sensitivity, empathy and active listening
skills that enable patients to make informed choices and future plans for themselves. It
was also stated that we need to be honest, compassionate, caring, hopeful and
informative and such events should be done in person, with privacy, at their pace, with
adequate time for discussion and in the presence of a supportive person. 

There are several methods that we can use such as the SPIKES Strategy, the
ABCDE mnemonic and the BREAKS Protocol. Such recommendations are intended to
serve as a general guide and should not be viewed as overly prescriptive, especially
when we try to apply such methods to our patients. She also included a discussion on
special issues which are relevant to our practice, such as a denial response which can
be a coping mechanism to protect oneself against distress; patient’s prognosis, wherein
awareness of prognosis has been associated with greater satisfaction and lower
depression levels; anger, which is a normal response to bad news and we need to
acknowledge it and avoid being defensive. 

These are all useful recommendations that I could apply to my future patients. I
still consider it as an unpleasant task but it is something that I am willing to endure. I
still have a few more years to practice my communication skills and hopefully, I will be
better in the mere future. 

Let me end this reflection paper with the following insights I have read from
aafp.org: “A growing body of evidence demonstrates that physicians' attitude and
communication skills play a crucial role in how well patients cope with bad news and
that patients and physicians will benefit if physicians are better trained for this difficult
task. The limits of medicine assure that patients cannot always be cured. These are
precisely the times that professionalism most acutely calls the physician to provide
hope and healing for the patient”. 

I hope these statements remind us that at times when everything feels hopeless
and when all the means have been exhausted, may our manner of dealing and
communicating with patients provide hope and comfort, even though death may be
imminent.