Doctors learning how to break bad news

PEORIA, Ill. -- When Dr. Julie Wohrley was in medical school almost 20 years ago, there was no lesson on breaking bad news to patients.

In fact, she was taught never to show emotion, even when saying the worst.

"There was no formal education. We mostly learned while we were caring for people, on the job," said Wohrley, a pediatric intensivist at Peoria's St. Francis Medical Center.

And while Wohrley said she eventually did reasonably well at it, there were doctors who stumbled though every bit of bad news they delivered.

But, luckily, things are changing, Wohrley said. Not only are doctors being taught how to share unfortunate news with patients, they are also learning that it "is OK to be human."

"People learn now that it's OK to empathize with your patients," she said. "You need to spend time and listen to what they have to say. It has been a huge improvement.

But no matter how long someone practices medicine, the job of bearing bad news doesn't get any easier, Wohrley said.

"If anything, it gets harder as time goes by," she said. "It is so stressful. It is definitely part of what doctors have to be very good at."

Wohrley prepares to give bad news by asking patients questions about what they already know.

"Hearing what they have to say puts me in the right frame of mind for telling the information," she said. "If they say, 'My child is going to die,' they are in a different place from the family that says, 'I know in my heart of hearts he is going to make it."'

Certainly there is shock and disbelief and grief, and doctors have to allow time for patients and their families to process what has been said.

"I just feel hopeful that I can provide emotional and spiritual support ... that they know we have done everything we can," Wohrley said. "There have certainly been times when I have felt overcome by sadness. Sadness for the child and for the loss of hope. You have a baby and all these hopes and dreams and suddenly somebody tells you all these hopes and dreams are gone."

Some of those instances stand out in her mind, including the time she told a 13-year-old boy he was dying.

"It really surprised me -- his response. I think he was well aware he was going to die," she said.

More research is now being done to find better ways to deal with patients at such times.

"There are a number of things we try to talk about today," said Dr. Rick Miller, who teaches at the University of Illinois College of Medicine. "We are beginning to understand emotional processes better. This has been an evolution."

"We know there is more to medicine than physiology and technology," said Miller, who has spent 25 years working in emergency rooms."

Dr. Robert Buckman, who presented a medical seminar on this topic last fall in Peoria, has come up with a protocol to break bad news to patients because it was something he was uncomfortable doing.

"I felt I did not know how to do it ... I thought I was the only one," said Buckman, who practices in Toronto.

But after talking with other doctors, Buckman realized no one had a good grasp on the problem.

"There were no guidelines. Nobody knew how to do it," Buckman said.

Buckman's steps include:

Find a private setting, with both physician and patient comfortably seated.

Start with a question to indicate to the patient that this will be a two-way affair.

Find out how much the patient knows and how much the patient wants to know.

Give the information in small chunks, and be sure to ask the patient if he or she understands.

Respond to the patient's feelings and plan a follow-through.