Breaking Bad News to Patients

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I carried the knowledge like a millstone chained around my neck, my back aching from the emotional weight of bad news not yet imparted.

Earlier in the morning, before a clinic packed with waiting patients, I scanned the electronic medical record for laboratory results of the people I was about to see. It is rare that any of these return without the telltale asterisk indicating a value that is out of the normal range.

All of my patients have cancers of the bone marrow of varying severities, and thus disturbingly low or high numbers of white or red blood cells or platelets, leaving them prone to infections or bleeding complications. Over time, I have become used to treating people with these apocalyptic lab results, and even managing them for the majority of their disease course outside of the confines of the hospital.

What caught my eye that morning was the presence of blasts in one of my patients’ lab results. Blasts are immature white blood cells. We all have some blasts in our bone marrow; without them, we could not develop a working immune system. To have any blasts in the bloodstream, though, is abnormal. And these cells accounted for 5 percent of my patient’s white blood cells, indicating his leukemia had returned.

My patient was in his mid-30s and had mild intellectual impairment, with an I.Q. that probably fell shy of three digits. When I first met him and told him about his leukemia diagnosis, he was living with his mother and employed at a factory doing piecework.

These conversations are never easy, as we try to communicate a flood of information about the cancer itself, and the risks and benefits of chemotherapy, often within hours of a patient’s arrival in the hospital. It is particularly challenging to do so with someone who may not understand why he has even been admitted to the hospital, never mind the severity of his illness or why it necessitates treatment with drugs that could make him feel even sicker, or hasten his death.

His mother, who was his power of attorney for health care, sat in a chair by his bedside. She was dressed plainly and reminded me of the subject of an Andrew Wyeth painting, her face tired, but kind. I pulled up another chair to join them.

“Do you know why you’re in the hospital?” I asked.

“Yup,” he answered. I asked him why.

“Because I’m sick,” he said, giving a quick look over to his mother for affirmation. She was silent, smiling grimly.

“Do you know what your sickness is?” I probed. Again, he glanced at his mother, who sat impassively. She seemed to be letting him take the lead with this conversation, lending her quiet support. He looked back to me.


I estimated he had the intellectual capacity of a 10-year-old and explained his diagnosis and how we proposed to treat it as I had in the past to children of my patients, or to other patients I have treated who had cognitive impairments. Leukemia occurs more frequently in people with Down syndrome, and we saw about one patient each year with both diagnoses, though in his case the cancer did not appear to be tied to the syndrome. When I finished talking, I asked if either my patient or his mother had any questions.

“No,” he quickly responded, and again turned to his mother, as did I. A psychiatrist had already seen my patient and had determined that he lacked the capacity to make informed decisions about his health care. I felt torn. He was my patient, yet legally his mother would be the one to give us permission to proceed.

“I don’t have any questions.” She spoke, for the first time. “Let’s get him treated.”

“Do you agree?” I couldn’t help asking my patient.

“Yup!” He answered. So we got started.

Luckily, he did extremely well with the chemotherapy, quickly going into a remission which he maintained for months, and tolerating the subsequent rounds of chemotherapy we gave him marvelously. But, as I had learned that morning, the blasts had returned.

I braced myself before entering his clinic exam room. The millstone always felt heaviest the moment before it was unloaded. I knocked on his door and entered.

“Hi,” I said to my patient and his mother, with a wan smile. They greeted me back as I sat down. I looked him in the eye and glanced quickly at his mother, then began: “I’m afraid I have some bad news.”

I know some doctors who engage in light conversation with their patients before telling them their cancer has returned, but I have always felt that to be disingenuous. At the same time, it’s unfair to spring this information on people without preparing them for what they are about to hear, and having a clear plan of action at the ready. I did just that with my patient, as he glanced anxiously back and forth between me and his mother.

“So, are you willing to come into the hospital for more chemotherapy?” I asked him, when I had finished.

“Yup,” he said, as we both looked to his mother. She nodded her affirmation.

I left his room, but didn’t feel any lighter. I no longer shouldered the burden of my patient’s cancer’s return alone, but felt sad because his cancer had recurred. And as an adult oncologist, I still couldn’t quite resolve how to navigate my duty to this man I cared for, and having to get permission to do so from another adult.