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In breaking bad news, the comfort of silence

In this piece, a fourth-year medical student shares a recent patient encounter and what he's learned about breaking bad news to patients.

Note: Certain details in this entry have been omitted or changed to protect the identity of those involved.

I can usually find something in common with a new patient to put our relationship at ease — maybe a mutual distaste for hospital food or even a stronger mutual distaste for New England sports. But for my last patient, the process of forming a congenial bond with him was to no avail.

His family is Irish. Mine is Chinese-American. He was a veteran. I’ve been in school my entire life. He lived in the south and was a devout religious man. I’m from the northeast and I could count on one hand the number of times that I’ve attended church service. He enjoyed spending time with his grandchildren and tending his garden. I enjoyed watching cooking shows. That is all to say, we had nothing in common.

He also just had a stroke and was left completely paralyzed on his right side. He could neither bend his fingers nor wiggle his toes. Pokes with a sharp needle would go unnoticed if he closed his eyes. He slurred his words and had trouble swallowing solid foods.

As I discovered after a literature search before rounds, the prognosis for my patient wasn’t reassuring. To my dismay, only around 1 out of 8 patients would go on to make a full recovery and eventually regain full function of their limbs. But that was a truth I hesitated to tell him. After all, I can’t imagining professorially explaining to my patient, “According to the latest research published in a reputable peer-reviewed neurology journal, the chances of you regaining full motor and sensory function of your left arm is 12.5 percent.”

There are some truths in medicine that are left best untold during particular situations and this was one of those; withholding the truth was not an act of omission but preservation. Hope is delicate, particularly when patients are at their sickest. He had weeks, probably even months, of hard physical rehabilitation ahead of him and he also had a high risk of having another stroke. What motivation would be left if he knew that he may have to live the rest of his life with a handicap? Maybe his outpatient doctor would eventually reveal to him his sobering prognosis or maybe he would find it himself online but at that moment, I spared him and his wife the frank statistics.

Instead, what I decided to tell him was that some improvement was still possible. He may never be able to throw a fast ball again, but at least he will eventually be able to use a fork again. But, he and his wife did not receive the news well.

There is a script that we're taught to follow when breaking bad news. We begin by making the patient comfortable, then proceed to tell him the bad news, answer any questions, show empathy, and finally end with a discussion on the future. But with him, I couldn't muster myself to go by a formula. It’d be disingenuous.

I had an attending who once told me to never tell a patient that you understand what they're going through because you simply don’t. You can’t feign authenticity and you certainly can’t manufacture empathy. His life and mine were oceans apart and only briefly intersected that week by unfortunate chance, a rogue artery in his brain that finally gave up. I didn't know what was going through his mind and I couldn't even begin to comprehend his worries.

There was no script for that situation. Instead, I remembered the rest of what my attending said: to simply not say anything, even if it leaves you and the patient in uncomfortable silence. He and his wife didn’t need to be reminded of treatment plans or be taught or preached to; what they needed at that moment was another human presence. I may not have been able relate to what they were going through, but I could acknowledge their concerns and share the hope that he would eventually be able to go back to tending his garden and be able to pick up his grandchildren.

The script for breaking bad news was published almost twenty years ago. If I had to rewrite it now, I’d tell the doctor that it's okay to let silence wash over the room. For those occasions when you can do nothing more, that's often the best you can do.

Stanford Medicine Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

Steven Zhang is a fourth-year medical student at Stanford and a Howard Hughes medical research fellow at the University of California in San Francisco. When he’s not in the hospital, you can find him on a run around campus or exploring a new hiking trail. 

Photo by dimhou

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