El arte de comunicar: de médico a paciente (actualizado el 5-09-2008)

El Dr. Rob ofrece en su blog algunos consejos sobre cómo dar malas noticias a los pacientes:

It happened today.

It’s a sinking feeling in the stomach.

The patient comes into the office with a chief complaint and set of symptoms that worrisome, or the x-ray comes back with a “suspicious area” on it.  It sounds like cancer.  My mind explores the possibilities, hoping for a diagnosis that is not so bad, but the elephant just won’t leave the living room. 

Having practiced for many years, I have had to give bad news many times.  It does get easier, but it never is easy.  I am standing at a major turning-point in a person’s life.  The words that come out of my mouth will hit them like a sledgehammer, shattering what is “normal” and leaving an uncertain future.

There are a few things that I have found are most helpful in this setting:

  •  Don’t beat around the bush – most of the time they already suspect something is wrong.  It does no good to use euphemisms.  If it may be cancer, then say “it may be cancer.”  It is extremely important that your wording is specific, not vague. 
  • Give a specific plan – It is extremely important to give patients something to focus on in the immediate future.  Answer the “what now?” question.  I usually call the specialist in person and get an appointment right away.  I don’t leave the scheduling to my nurse or referral coordinator.  It is extremely important for people to walk out of the office with a plan.  Their lives are suddenly full of uncertainty, so it’s not right to add to it.
  • Don’t conjecture – I try to stick with what I know for sure.  I try not to answer questions like “how long will I live?” or “will I need chemotherapy?”.  My job is to get them to the next step.  A “mass” is not the same as “adenocarcinoma.”  If these questions are asked, I tell them that the specialist will make the diagnosis and then the longer-term plan will be more clear.
  • Don’t make them wait – If more tests are needed, don’t schedule them for two weeks – even if it would not matter clinically.  It is simply cruel to tell someone they might have cancer and then make them wait to know what it means. If necessary, I schedule the scan myself or talk to the radiologist to get it scheduled.  If an oncologist or surgeon schedules an appointment for two weeks (or even 3 days), I call them personally and ask to get the patient in sooner.  Today, if possible.
  • Bring them in – It is awful to call someone and say, “your doctor wants you to come in and go over your test results,” but it is worse to give those results over the phone.  As uncomfortable as it is in person,  it is important that you are with them.  It shows that I understand how earth-shattering this news is.  To do it over the phone makes it seem like you don’t care.
  • Don’t try to find “silver linings” – I have had many cancer survivors tell me that their cancer really helped them see what was really important in life.  But that means nothing to someone who just got bad news.  Once you say the word “cancer,” any thing you say to try to make things better will fall on deaf ears.  What people need is your sympathy and a clear plan – that will comfort far more than any platitude.
  • Give comfortSympathy literally means to feel pain alongside someone.  You feel pain.  The pain you feel giving bad news is shared with their pain receiving that news.  I also will give these people special access to me if they need anything – my cell phone or a back line number.  They need to know where to get answers.  Also inquire about support systems – do they have family in town, or a church they belong to?
  • Follow up – I don’t just pass people over to the specialist.  I want them to still be my patient.  I either ask them to call when they know what is going on, or I call them myself after a reasonable length of time.  If necessary, I even schedule them to come in simply so I can hear what is going on.  This makes people feel less isolated and gives a chance to ask questions.

One of the great honors of being a doctor is to be there at the critical times of a person’s life.  Not all of those times are not happy.  I think people need you most as a comfort and help at these times.  It is very hard for a doctor to cause pain by their words.  But the way in which bad news is given can either add to the pain or start the healing process.


Más información sobre el tema:

ACTUALIZACIÓN (5 de septiembre de 2008):

Un pensamiento en “El arte de comunicar: de médico a paciente (actualizado el 5-09-2008)

  1. Pingback: La importancia de comunicar malas noticias en Medicina « Biblioteca Médica Virtual – Blog

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