Delivering heartache


How many times am I the person who gives the news that destroys someone?

How many people in the area we serve, remember my face as the one who broke them? I wonder if they ever recognise me in the line at the post office, or passing by them in the supermarket aisle.

A man's wife calls an ambulance after he has a seizure and a scan shows a brain tumour pushing his grey matter tight against his skull. My words are careful, practised in my head before we meet, calibrated with each experience. The hospital is noisy, always moving, but in this room time stands still. 'I am so, so sorry' I start and his wife inhales deeply and closes her eyes. My face at this moment is her worst nightmare.

We're trained in breaking bad news from the time we start medical school. There are formats to follow and studies that teach us that after we say terrifying words like cancer, little else will be heard. We deliver information in small pieces, answer questions, give time for reflection. Each year there are workshops to practice and receive feedback and we constantly learn watching our seniors deliver heartbreak.

'This must be bad news if you've asked my daughter to come in to hear the results', my patient tells me. It's not a question, it's a statement. This is a breaking bad news technique called flagging, where I've set the scene by making a time to explain the results. 'Let's not discuss this on the busy ward round, let me come back at 2pm when I have more time.' I'm setting up the landscape of this horrible moment to minimise the trauma. A family member to hear the news with them, a box of tissues, a door that closes, someone else to answer the emergency pager for those 20 minutes - small, almost frivolous details, but simultaneously crucial details of utmost important when this memory becomes etched in someones life.

I vividly remember being told my much adored nana had cancer. I was wearing stockings with a tear just below the right knee that I hadn't noticed until that moment. The cancer was incurable and nana was going to die. My favourite person's life suddenly had a time limit. I couldn't breathe. The world was crashing down around me and I couldn't quite make out the doctor's words clearly after that. I wished I wasn't wearing laddered stockings.

As doctors, these conversation topics - death, cancer, disabling strokes, bad outcomes - are, by their nature, horribly uncomfortable. Some practitioners go to huge lengths to avoid them. When faced in a room with six weeping daughters and a despondent patient, our palms sweat and we feel anxious. Suggesting another day of antibiotics, another round of chemotherapy, a blood transfusion that we know is futile, is an enormous temptation. Propositions like these are latched onto and hope becomes a palpable presence in the room. The crying stops and even we might convince ourselves this could work. 'Thank you doctor, thank you', they say. The difficult conversation has been postponed, to another time, perhaps even to another doctor. I teach my interns and students that we need to sit with the uncomfortable conversations, to become fluent in our own discomfort to treat the suffering of others. To not flinch at death, to not avoid the difficult conversations.

....

My hardest conversation so far in my career was breaking the news to a colleague that their father had incurable cancer, discovered after he was admitted under my team with a relatively minor ailment. I sat for an hour in the bathroom, feeling nauseated to my core, practicing words and phrases, trying to stop my hands from shaking. I'm about to become the worst memory of this doctor's life, will he look at me every day from now on with pure loathing? For nights after I cried, and cried, and cried.

This week, after leaving a family with their dying grandmother, I suddenly felt the weight of every family meeting, every bad news I've broken on my shoulders. I graduated medical school 5 years ago and have already delivered so much pain. So, so much pain. In 50 years time, at the end of my career, what will be the cumulative heartbreak I've bestowed on others?

How many 'I think your mum will die today' and 'you need to call in the whole family' and 'this is unsurvivable' and 'I'm sorry but it's cancer' conversations will I do in my lifetime? How many people will I watch crumble in front of me? How many screaming mothers will I comfort? How many sobbing husbands will I sit with? How often will I be the person that delivers the news that destroys someone?

Doctors cope with this in different ways, but I will not take the advice of those who say its best to become more distant, to not feel things as deeply, to be less involved. After hundreds of these moments, the words and the process have become easier, sure, but I hope death and pain never become easy for me. A senior doctor once told me the deaths don't affect him because he disconnects the person from the disease - its easy to accept a death from a 'severe brain haemorrhage', whereas accepting that Tom the retired boilermaker with eighteen grandchildren who call him grumps will not survive this brain haemorrhage is harder. In 50 years time, I don't want to have cared for hundreds of illnesses, but hundreds of people, even if feeling the pain means more work and reflection as I go.

I hope I am always aware that my everyday is my patients worst day. This may be my hundredth cancer or the uncountable time I've said someone is dying, but its that persons first cancer. This is the first and only time someone's partner or mother is dying. I've said this spiel a hundred times, but they will remember my words for the rest of their life. I'm the person that delivers the news that destroys them.

....

My best friend is an obstetrics registrar and at dinner last night, she asks which wine pairs best with telling a mother her baby has died inside her at 32 weeks. My job is at the other end of life, and that afternoon I'd sat with a 96 year old man as his wife of 70 years passes away quietly from pneumonia.

We choose a light, crisp pinot grigio to contrast our heavy hearts.

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