The Difficult Balance of Giving Bad News

The medical logic is perfect: the patient has suffered a catastrophic brain injury, and it is unlikely that she will ever wake up again; my other patient will likely need the ventilator for many more days and will need a surgery to connect the airway to his neck, called a tracheostomy. To me, as an ICU doctor, it is completely logical and rational.

To a loved one, however, those words are absolutely devastating. Telling a daughter that her mother will never wake up is just as catastrophic as the initial brain injury. Telling a mother and father that their son will need to live on a ventilator for weeks, if not months, is equally catastrophic. As the clinician giving this news, it is sometimes hard to see how catastrophic those words truly are.

On the one hand, I need to be objective and rational, not taken in by the emotion of the moment, so I can explain the medicine as cogently and completely as I can. It is important that I give my patients’ families accurate facts and data, so we can all make the most informed medical decision possible.

On the other hand, when I am totally enveloped in the medicine and its logic, it can be hard to see why what I am saying is causing so much distress on the part of the family. “What is so hard to understand or accept?” I may ask myself. “The medical logic is absolutely concrete and linear.”

But, I when I am giving bad news to family, I am no longer in the realm of “medical logic.” I am in the realm of emotion, devastation and catastrophe. Families cling to every single word I say, and sometimes they are trying to hold on to any semblance of hope in my words. It can be hard to fully understand this, and this is where we doctors are liable to come off as callous and uncaring.

But it’s a difficult balance to achieve: being objective and having understanding of how terrible the news can be coming out of my mouth. I’ve been there myself with my own daughter, when she died in 2009 after suffering septic shock. It is essential to remind myself that families do not live in the realm of “medical logic” so I can maintain empathy and not fall prey to callous heartlessness.

Having a loved one be critically ill and die is a horrific experience. As I have written before, I would not wish it on my worst enemy. Those of us in Critical Care Medicine give our all to try and save those patients entrusted to our care. We fight like hell until we either win, or the fight cannot be won despite our every effort.

Let us always be cognizant of the fact that our patients’ families are watching that fight with fear and trepidation. When it is time to give bad news, let us remember how devastating our “medically logical” words can be to them and deliver those words with the utmost care and compassion.