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Breaking bad news
DISSECTING ROOM
LIFELINE Jackie Leach Scully Jackie Leach Scully took her PhD in molecular biology at Cambridge University, Cambridge, UK, and continued with cancer and neuroscience research and science communication in Switzerland. She is at the unit for ethics in the biosciences at the University of Basel, Basel, Switzerland, where she lectures in bioethics and disability studies. What would be your advice to a newly qualified doctor? Listen to what your patients are telling you by what they’re not saying aloud. What is the best piece of advice you have received, and from whom? Don’t tailor your interests to what’s in fashion (Margaret Spufford). Take your holiday entitlement (Paul Edwards). How do you relax? Laughing, reading, having a foot rub. What is your greatest regret? That I listened to the tutor at Oxford who told me not to take history and philosophy of science as a fourth-year option. What is your favourite film, and why? A Matter of Life and Death, by Powell and Pressburger: it’s visionary, thought-provoking, sly, and has that wonderful staircase. What are you currently reading? A Question of Intent, by David Kessler. Do you believe in capital punishment? No. It’s barbaric; it denies the possibility that people can change; and revenge killing can’t erase the original harm. Do politics, spirituality, or religion play an important part in your life? Yes, and by being a Quaker I get all three. Describe your ethical outlook. Indelibly shaped by the nun who taught me that in situations of ethical difficulty, many questions need to be asked but the first should always be: who’s getting screwed? Being clear about that is the first step towards rectifying injustice. Do you believe in monogamy? For me, yes. But I don’t prescribe. What is your favourite non-medical website of the week? http://www.chernobyl.info/en.
958
Breaking bad news hysicians write volumes about breaking bad news. None of it helped me with Mr Price. Mr Price was 89 years old, a powerful man who owned half the county. He was also surrounded by minions who followed his orders unquestioningly. If he wanted to stop or to double a medication, or to try another prostate operation, it got done. I saw him every week to prevent that. Mr Price was something of a legend as a rich, liberal democrat —a rather rare creature, especially in Texas. He had integrated his many businesses years before the first civil-rights legislation, and was famed for his corporate largesse and individual acts of kindness. Mr Price was always accompanied by a cowboy, one of the large, stolid men who had worked on his ranch for many years, and now in their 60s, had evolved into full-time caregivers. But he was driving his family and employees crazy. Every day he went to his office, and by lunchtime was tired and irritable. This man, whom his family and workers had always seen as a saint, was becoming a tyrant and a bully. Mr Price trusted me. When I first saw him I had stopped monthly injections for non-existent prostate cancer and started him on an antidepressant and angiotensin-convertingenzyme inhibitor, and his gratitude at his improvement in wellbeing did not diminish, even though the benefits of my manipulations did. Mr Price did not want to die, and did not want to talk about it. He would deftly change the subject whenever I tried to talk about his outlook. As his mental powers diminished, his brain was constantly in the “send” mode of telling stories and giving orders, and rarely in the “receive” mode of listening and empathising. The cowboys and Mr Price’s adult children telephoned with tales of nasty
P
verbal abuse. But no drugs seemed to help, and Mr Price refused to discuss the issue with me. Mr Price was stylish. He wore elegant cuff-links and bolo ties. He was a polished raconteur, with a stable of stories involving famous Texans. He could always make me laugh. And, he was a gentleman. Hence the tragedy of his recent nastiness. One day I decided that I would have to confront him, so I stood in front of him and almost screamed, “Mr Price, I’m sorry, but you are seriously ill. I really don’t think you’re going to live that long. I never know anything for certain, and I’m wrong all the time, but I really don’t think that you’ll be alive in a year.” Why did I do that? It was almost an assault. I knew that he did not want to talk about death, and I almost always do what my patients want. But this time something snapped, and I pushed the bad news on him. He acted as if he hadn’t heard me. He changed the subject and told a joke. I felt guilty. I had not been a gentleman with Mr Price. I worried about whether he would come the next week, whether I could still cheer him up. A week later he greeted me with a big smile and two boxes, containing his beautiful cuff-links that I had often admired. He sent his cowboy out of the room and told me that this was only the second time in his life that he had given a man a gift. He died a year later, but in that year the cowboys told me that his mood had changed. He was no longer so angry, no longer trying to maintain control over all his possessions. Instead, he built an addition to the public library named after his late wife, and worked to develop literacy programmes for people in Texan prisons—a liberal and a gentleman to the end. James S Goodwin
THE LANCET • Vol 360 • September 21, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
LIFELINE Jackie Leach Scully Jackie Leach Scully took her PhD in molecular biology at Cambridge University, Cambridge, UK, and continued with cancer and neuroscience research and science communication in Switzerland. She is at the unit for ethics in the biosciences at the University of Basel, Basel, Switzerland, where she lectures in bioethics and disability studies. What would be your advice to a newly qualified doctor? Listen to what your patients are telling you by what they’re not saying aloud. What is the best piece of advice you have received, and from whom? Don’t tailor your interests to what’s in fashion (Margaret Spufford). Take your holiday entitlement (Paul Edwards). How do you relax? Laughing, reading, having a foot rub. What is your greatest regret? That I listened to the tutor at Oxford who told me not to take history and philosophy of science as a fourth-year option. What is your favourite film, and why? A Matter of Life and Death, by Powell and Pressburger: it’s visionary, thought-provoking, sly, and has that wonderful staircase. What are you currently reading? A Question of Intent, by David Kessler. Do you believe in capital punishment? No. It’s barbaric; it denies the possibility that people can change; and revenge killing can’t erase the original harm. Do politics, spirituality, or religion play an important part in your life? Yes, and by being a Quaker I get all three. Describe your ethical outlook. Indelibly shaped by the nun who taught me that in situations of ethical difficulty, many questions need to be asked but the first should always be: who’s getting screwed? Being clear about that is the first step towards rectifying injustice. Do you believe in monogamy? For me, yes. But I don’t prescribe. What is your favourite non-medical website of the week? http://www.chernobyl.info/en.
958
Breaking bad news hysicians write volumes about breaking bad news. None of it helped me with Mr Price. Mr Price was 89 years old, a powerful man who owned half the county. He was also surrounded by minions who followed his orders unquestioningly. If he wanted to stop or to double a medication, or to try another prostate operation, it got done. I saw him every week to prevent that. Mr Price was something of a legend as a rich, liberal democrat —a rather rare creature, especially in Texas. He had integrated his many businesses years before the first civil-rights legislation, and was famed for his corporate largesse and individual acts of kindness. Mr Price was always accompanied by a cowboy, one of the large, stolid men who had worked on his ranch for many years, and now in their 60s, had evolved into full-time caregivers. But he was driving his family and employees crazy. Every day he went to his office, and by lunchtime was tired and irritable. This man, whom his family and workers had always seen as a saint, was becoming a tyrant and a bully. Mr Price trusted me. When I first saw him I had stopped monthly injections for non-existent prostate cancer and started him on an antidepressant and angiotensin-convertingenzyme inhibitor, and his gratitude at his improvement in wellbeing did not diminish, even though the benefits of my manipulations did. Mr Price did not want to die, and did not want to talk about it. He would deftly change the subject whenever I tried to talk about his outlook. As his mental powers diminished, his brain was constantly in the “send” mode of telling stories and giving orders, and rarely in the “receive” mode of listening and empathising. The cowboys and Mr Price’s adult children telephoned with tales of nasty
P
verbal abuse. But no drugs seemed to help, and Mr Price refused to discuss the issue with me. Mr Price was stylish. He wore elegant cuff-links and bolo ties. He was a polished raconteur, with a stable of stories involving famous Texans. He could always make me laugh. And, he was a gentleman. Hence the tragedy of his recent nastiness. One day I decided that I would have to confront him, so I stood in front of him and almost screamed, “Mr Price, I’m sorry, but you are seriously ill. I really don’t think you’re going to live that long. I never know anything for certain, and I’m wrong all the time, but I really don’t think that you’ll be alive in a year.” Why did I do that? It was almost an assault. I knew that he did not want to talk about death, and I almost always do what my patients want. But this time something snapped, and I pushed the bad news on him. He acted as if he hadn’t heard me. He changed the subject and told a joke. I felt guilty. I had not been a gentleman with Mr Price. I worried about whether he would come the next week, whether I could still cheer him up. A week later he greeted me with a big smile and two boxes, containing his beautiful cuff-links that I had often admired. He sent his cowboy out of the room and told me that this was only the second time in his life that he had given a man a gift. He died a year later, but in that year the cowboys told me that his mood had changed. He was no longer so angry, no longer trying to maintain control over all his possessions. Instead, he built an addition to the public library named after his late wife, and worked to develop literacy programmes for people in Texan prisons—a liberal and a gentleman to the end. James S Goodwin
THE LANCET • Vol 360 • September 21, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.