How Should Providers Deliver Bad News?

Neil S. Prose MD, Professor of Pediatrics and Dermatology at Duke University Medical Center
Michael Haglund, MD, PhD, Professor of Surgery at Duke University Medical Center

Introductory text: In this scene, Duke University neurosurgeon Dr. Michael Haglund (playing Dr. Anderson) demonstrates the wrong way to deliver bad news to patients and families.

Dr. Anderson: Mr. and Mrs. Jones, I am Dr. Anderson. I’m a neurosurgeon. The pediatricians called me because Jimmy had an MRI scan, and it looks like the MRI scan shows a brain tumor. I looked at it myself and it shows a lesion in the cerebellum, a tumor in the cerebellum, that we are going to have to deal with. So we checked out the OR [operating room] schedule on the way up here and it looks like Tuesday afternoon we can do a surgery.

Father [shocked]: Are you sure you were talking about the right person, uh…

Dr. Anderson: Yeah, little Jimmy, about 4 years old. I walked by his bed when I was coming up here. He was still just coming out of the MRI scanner.

Father: We thought he had the flu. I mean he’s just had some nausea and some headaches.

Dr. Anderson: I mean sometimes these brain tumors can push on the back of the brain, and where they push can cause nausea and vomiting and sometimes it mimics … No, it’s not the flu, it’s a brain tumor. So we set up the surgery for Tuesday. The pediatricians will come in and tell you what bed he is going to. I don’t know what bed he will be at. We will keep him in the hospital until Tuesday’s surgery. Looks like it’ll be in the afternoon. Any other questions?

Mother [struggling to find words]: When will I see him?

Father: Is he okay?

Dr. Anderson: He’ll be up here in a little while. I don’t know. I didn’t see him. I just saw him lying in the bed. The nurses are taking care of him. But uh… any other questions?

Mother: I just can’t believe it.

Dr. Anderson: Well, we may have some time to talk before the surgery on Tuesday, alright? Alright, well the pediatricians will be in a little bit, okay?

Introductory text: Now watch, as Dr. Haglund demonstrates a better way to deliver bad news.

Dr. Anderson: Hi Mr. and Mrs. Jones, I’m Dr. Anderson, the neurosurgeon. It’s nice to meet you [sits down]. Can you tell me a little bit about what’s been going on with Jimmy?

Mother: Well, he was sick last week. All this week, you know, throwing up, headaches, and just really intensely sick, and just not kicking it, yeah.

Father: And we know there is a flu going around so we just wanted to make sure it wasn’t anything more serious.

Mother: I just worry about his immune system …

Father: And they wanted to give him an MRI here.

Mother: They said to rule things out.

Father: He’s been gone for four hours. We’ve been waiting.

Dr. Anderson: So, he’s been sick for about a week? And throwing up and headaches? And I know you’ve been waiting a long time, and I’m sorry about that. They had to sedate him a little bit to get him to hold still for the MRI scan.

Mother: Is he scared? Is he okay?

Dr. Anderson: He’s okay. I just saw him. He was basically like waking up from a long nap, so he’s moving around, and he looks fine, and he’s opening his eyes, but he’s still not kind of back to his normal self yet. The nurses are watching him really closely and everything’s fine with him. I looked at the MRI scan. I’m afraid I have some bad news for you. It looks like he has a brain tumor.

Father [after pause]: Are you sure?

Dr. Anderson: Yeah, I checked very carefully the scan and him, and it fits with the symptoms he’s having. He’s got a small brain tumor back here in his cerebellum on the right side [gesturing to his head].

Father: We just thought he had … you know, we just thought it was … I mean we thought it was kind of silly that we came in today.

Dr. Anderson: Sometimes these present that way. The little kids are sick, and they’re having nausea and vomiting, but it turns out it’s actually pressure on the back of the brain that’s causing them to have the headaches and that kind of thing.

Mother: This is really a shock.

Father: I didn’t even know why they wanted to give him an MRI. We were …

Mother: Oh my God …

Dr. Anderson: I know this must be really hard news to hear.

Mother: Is he going to be okay?

Dr. Anderson: He’s going to be okay. We are going to be with you every step of the way. Would you mind if I tell you a little bit about what the plan is going to be? What the next step is, so we can keep taking good care of him?

[Mother and father nod.]

So, I can tell you one thing, looking at the MRI scan, sometimes you can tell if they are more slow-growing benign tumors, or more fast-growing, aggressive tumors. And the good news is, it’s the more slow-growing tumor, looks like. We won’t know for sure until we take it out. We are going to have to do surgery to get it out and try to cure him from this tumor.

Mother: So it’s just a benign one?

Dr. Anderson: We hope so. We’ll know once we look at it under the microscope, but looking at the MRI scan, that would be the more likely scenario.

Mother: That’s what it looks like? It’s not just … You’re going to rule out … I mean, it’s probably benign?

Dr. Anderson: Where it’s located, it looks like that, yes. So, we’ve looked at the schedule and we want to admit him to the hospital tonight, and we will keep him here over tomorrow, and give him some steroids to get the swelling down, so he’ll feel better. And then Tuesday morning, we’ll do the surgery. And the surgery will last about three hours.

Mother: A couple days, yeah. Can we see him? Is he …

Dr. Anderson: Yeah he’s going to be right up. The nurses we just about ready, they were getting him all ready in the bed, and, like I said, he was waking up from a long nap, and he’s going to be up here in about five minutes. And I know that’s a lot to take in, but, [pauses] what questions do you have?

Mother: I’m just so floored right now. I just ...

Father: How long do you think he’s going to be in the hospital after the surgery, if things go okay?

Dr. Anderson: If things go well, he should be able go home by next weekend. So, tonight’s Sunday night. So, he’ll have surgery Tuesday. Should be able to go home by Friday or Saturday.

Mother: He’s going to be okay? Just, he’s going to be okay.

Dr. Anderson: We’re going to be with him every step of the way with you guys, and if you want to, I’ll come back in a little bit and we can talk once you’ve have a chance to process a little bit of this stuff. We can talk with him and tell him he’s going to have to have a little surgery on Tuesday.

Father: Yeah, I think that will be helpful.

Mother: Yeah.

Father: I’m not sure what I would say.

Dr. Anderson: We’ll your job is just to be Mom and Dad. We’ll be the neurosurgeons, okay? We’ll take good care of him, alright? Alright, take care.