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Education  |   July 2015
Telling Him
Author Notes
  • From the Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania. morrisonw@email.chop.edu
    From the Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania. morrisonw@email.chop.edu×
  • Accepted for publication October 10, 2014.
    Accepted for publication October 10, 2014.×
Article Information
Education / Mind to Mind / Critical Care / Gastrointestinal and Hepatic Systems / Palliative Care / End-of-Life Care / Pediatric Anesthesia / Respiratory System
Education   |   July 2015
Telling Him
Anesthesiology 7 2015, Vol.123, 226-228. doi:10.1097/ALN.0000000000000509
Anesthesiology 7 2015, Vol.123, 226-228. doi:10.1097/ALN.0000000000000509
Dr. S walked through the door, white coat thrown over scrubs and a blue cap still on his head. My mother and I had been watching for him, and we stood so that he could more easily find us in the crowded waiting area. We were prepared for whatever he would have to say. Dad had gone into surgery that morning knowing he had a ‘mass’. In the office last week, Dr. S had talked about a number of things the mass could be. But it had been clear to me at least, as the saying went in medical school; cancer was #1, #2, & #3 on the differential. Dr. S took some time though to talk about other possibilities. Maybe he thought it might help my father tolerate a morning with no breakfast, no coffee, and multiple introductions to strangers in a state of undress. Or maybe it helped him feel better too.
No matter what he was expecting, my father would have waited calmly in the pre-op area that morning. He has always taken everything in stride. As a child, I never heard him raise his voice, unless the Crimson Tide football team could use a little running commentary from the couch to spur them on. The day of surgery he seemed no different. From all that anyone could tell, he was quietly waiting to see what was going to happen.
When Dr S found us in the waiting room, he confirmed what we had guessed. Clearly a tumor - cancer. There were still pathology results to come, and like surgeons everywhere, he thought he “got it all.” We latched on to every hopeful reassurance. But one fact remained. From this point on, my father was a cancer patient. As the physician in the family, I began to think of all that would come next.
After a half an hour wait, a nurse called us back to Recovery. Mom and I walked to the corner where curtains surrounded a bed. As I stepped through them to take a seat next to the gurney, I saw Dad was still groggy from the anesthetic. Dr. S had gone back to the operating room with his next patient. I had no idea if he had updated my father about the procedure, but even if he had, there was no way Dad would have been able to remember a word he had said. It had not occurred to me that Mom and I would be sitting there, waiting for Dad to wake up, knowing information he probably did not yet know. The weight of that knowledge stayed with me, and I found myself watching him closely and wondering how long until he would be fully awake. I began to realize it would likely be left to us to tell him.
I’ve studied how to give bad news. I’ve taught classes on the topic, written about it. Working in critical care and palliative care, I have to give a patient or a family bad news almost every week. Yet no amount of experience in doing so as a part of my job could completely prepare me for taking on that role as a family member.
Ask permission.
Dad slowly woke up more and more. He nodded to us as he realized we were there, and asked how long he had to wait to get that cup of coffee. Once he was sitting up in bed and propped up on some pillows, he talked a bit about the rest of the day and which family members had already been by.
There was probably no point in waiting longer.
“Dad, Dr. S came out to talk with us after the operation.” A nod. “Do you want me to tell you what he said?” This time a pause, and then another nod.
Start with what they know.
“Do you remember, did he talk with you at all?” Now he shook his head to indicate no. I didn’t really think it was likely he had. Asking about the conversation in clinic last week seemed silly so I moved on.
Speak in short sentences.
“Everything went OK with the operation. It was just like Dr. S said it would be. We are going to be waiting a while on some pathology tests. Dr. S did say that he was able to tell it was a tumor. Like he had talked with us about. It is almost certainly cancer.”
There. I said the word.
Allow silence.
A few slow nods in a row, with a slight twist of the lip. Otherwise quiet.
“Do you have any questions about that?” None.
Any emotion is to be expected.
Handling an emotional response is certainly easier when everyone is calm. No tears, no anger, no obvious denial. But as I thought about my father, maybe his being quiet didn’t mean there was no emotion there. Did quiet mean he was ready to take this on? Or was he numb? Silence should never make me think he isn’t worried, or that he doesn’t need some reassuring words. I needed reassurance too.
I also realized a quiet patient doesn’t mean it’s a conversation one should move away from quickly. But here I had one advantage – I was not his doctor, and he was not my patient. There was no one waiting in the next clinic room, no backlog out front for me. If he wanted to be quiet, I could sit quietly too. My guess was that was what he needed most. Working with children, I know that one of a child’s greatest needs when times are tough is to know that she is not alone, that her family is at her side. Perhaps adults are not really all that different. There would be plenty of time to talk, so there was also time to let everything sink in.
Do surgeons think a lot about what they tell their patients and when? Do they ask the patient before going into surgery if it is ok to talk with the family afterwards? Or is that only in unusual situations, where particularly sensitive problems may be diagnosed? Or only when it is obvious the family interactions are strained? Like so many things in medicine, these were questions that had not occurred to me until I was on the “patient” side of the doctor-patient interaction.
Prepare for the next steps.
“We’ll know a lot more in a week or so. It sounds really hopeful that it is a kind that responds very well to therapy.” He knows we don’t have all the answers yet.
There will be much more to come. There will be appointments with oncologists, radiation, trips back and forth to the hospital and clinic. My mother will always be at his side, and I will be on the phone, asking how it went.
What comes next is also learning what this means and how his life will change. He will always be so much more than a cancer patient. He will be a husband, father, grandfather, brother, community member, businessman, sports fan, a lover of the land and animals, and a steady presence. Considering that he is much more all of these things than he is a “patient,” maybe it is apt that he heard this news from family. From those who will be there no matter what the future holds.