A bad diagnosis is horror – but it has to be delivered. The doctor Jalid Sehouli is concerned with the question of whether this can be done in a good way.
Professor Sehouli, did you have bad news today?
Yes of course. On average, I have to tell a patient about three times a day about a finding that will seriously change her or his life, maybe even shorten it dramatically. Incurable illness, dying, death: these are the big issues that I have to discuss with people.
You'd think doctors were well versed in this.
Many are not. They fear this exceptional situation just like the patients. They avoid the fear and anger of those affected – and their questions to which they have no easy answer. Unfortunately, this is not only the case in the medical profession. Most executives in Germany are not prepared to announce dismissals. I try my best without hiding the fact that I work to get better almost every day.
Why is it so difficult?
Because you feel bad about it. In fact, when I deliver a message, I feel partially guilty that the therapy I suggested was unsuccessful or because I didn't cry with it. I then think that I am more than a messenger – more of a perpetrator, a causer. But it is precisely the art of dealing with bad news: not focusing on yourself, but on the needs of the recipient.
How do you tell a person that they are likely to die?
The most important thing is: it's about the person, not the disease. Unfortunately, doctors forget that far too often. And: It's not about the exact words. Much more important is the attitude with which you seek such a conversation and how you shape the relationship.
What do you mean by that?
Whether doctors deliver a devastating diagnosis, police officers a death notice, spouses a decision to split up, bosses a termination: The basic principles of communication are very similar in all of these. First: Basically, you should deliver bad news in person, not in writing or over the phone or text message. Second, you need to prepare for the interview. Think about what exactly you want to convey and what reactions it will probably trigger, sadness, anger, shock, crying. Third: At the beginning of the conversation, you should ask if the other person feels ready to take on a difficult message. After this little warning, you should consciously take a short break – to slow down the dialogue and to give the emotions and thoughts some space. It's like a rear-end collision. It's easier to survive if you slow down your speed, are prepared and buckled up. Fourth, ask which other people should leave or join the room. As you speak the message, try to maintain eye contact and exude stability and calm.
What's next?
Studies have shown: On average, people need about 18 seconds to orientate themselves after receiving bad news. This time passes before the content of the message is understood. The messenger, however, can usually endure a maximum of 16 seconds of silence – and then begins to speak again. This discrepancy is often fatal.
Why is that so?
Silence is an important element in existential conversations, especially those about bad news. Because silence gives you strength to catch your breath. As a rule, the recipient does not find them unpleasant at all. Rather, it can awaken a feeling of security and strength in him. Because in the silence it becomes clear: We are now together at this bad point in life! The philosopher Arthur Schopenhauer once said in a general sense: Nobody should miss the chance not to say something. This is especially true in extreme situations.
But concrete solutions – can you talk about that?
It is human to want to immediately counterbalance the bad news. But often it happens too quickly. Many people, including doctors, do not know that anyone who receives a message that affects them existentially can no longer concentrate. And not only that: We can then see worse, smell worse, hear worse, feel worse. The organism is so alarmed that the absorption capacity is severely restricted. Perhaps then overwhelming emotions arise, the body reacts with tears, weakness, nausea. It takes time to be able to speak rationally again.
How do you deal with strong feelings in the other person?
No matter which emotion arises: it needs space. As the messenger, I try to look calmly at my counterpart. I signal with my posture and look that his or her pain is the greatest in the world now.
Can you touch the other?
That depends on the relationship between deliverer and recipient. If they are close, a hug can help, of course. However, if you have never held each other's hand, it will probably not do any good even in the extreme situation. If, as the messenger, you yourself feel the strong impulse to want to touch, you should examine this carefully and, if possible, redirect it to another gesture, for example handing your counterpart a handkerchief, pouring a glass of water.
And then?
After a while you can also look for solutions, but at first only for obvious solutions, for what might help now: Should I call someone? Can i get someone How do you get home? Should i stay with you today These are questions that are important at this moment. Not those that concern the distant future. Of course, this does not apply if the recipient has questions himself. The answer is to be as comprehensive and honest as possible. Because he is, so to speak, the clock of the conversation.
Should you really be ruthlessly honest in this situation?
I dont lie. But as the deliverer, you still have the opportunity to keep asking how many details the recipient would like to know. It is not uncommon for my patients not to want to know everything.
What do you answer to the question: "How long do I have to live, Mr. Sehouli?"
I say: "I am a scientist, but statistics are also misleading. X percent of patients with your findings die after Y months. But the others live longer, some contrary to all prognoses. And we do not know which group you belong to! " Then I try to steer the conversation away from the numbers, like asking: "What is important to you?" Or: "What else would you like to do?" And when I know, I say something like: "Let's try it together!" Or: "That is a distant goal – can you think of one that can be achieved a little earlier? I will not lose hope." In almost all conversations, sentences like: "I would like to see my daughter's wedding" or "I want to be at my son's lantern festival" – and I answer to the best of my knowledge and belief whether I believe that this is achievable or not .
Many bad news bringers try to offer comfort and then begin to share what bad news once happened to them.
That is humanly understandable and empathic. It is the intuitive signal for: I know that, you are not alone. Unfortunately, many people quickly lose sight of the fact that it is actually not about themselves. And what has helped me doesn't have to help the other. My recommendation: If it is important to you, tell us briefly about what happened to you once. But then return to the present situation. The phrase "I know how difficult it is" is often received very negatively, and those affected perceive it as an empty phrase. Also, please never say, "I know how you feel." That is simply not possible. Because the same thing can feel like a two for one person on a scale from one to ten, and an eight for another. Rather, say, "I can imagine how you feel."
PROF. DR. JALID SEHOULI is a globally recognized cancer specialist at the Berlin Charité. He has published a book on doctor-patient communication, but also writes novels.