Breaking Bad News
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63 Breaking Bad News I’m just about to flip open the patient’s chart to find out why she is here when I see a note stuck on the front of the folder. “Positive for chlamydia,” is scribbled in the secretary’s handwriting. “Here for treatment.” I’m tempted to let one of the residents deal with this patient—but it’s highrisk pregnancy day and we’re sure to get backed up. Anyway, I’ve been a nurse for years. Giving bad news is part of my job. Reviewing the chart, I read that the patient, Ellen, is in the fourteenth week of her first pregnancy. Three days ago, she’d experienced burning with urination and vague pelvic pain. She’d come to the clinic, terrified that something was wrong with her pregnancy. The resident who saw her collected a urine culture to make sure Ellen didn’t have an infection and did a pelvic exam, checking for simple infections, like yeast, and culturing for more serious infections. Yesterday the nurse called and left a message on Ellen’s phone: Come into the clinic tomorrow. We have your test results. Looking at the chart, I find that everything came back negative except the cervical culture. Ellen has chlamydia, a sexually transmitted disease, and I’m the one who must tell her. Giving bad news to patients is a special talent, something no amount of education can teach. When I was in nursing school and, later, in nurse practitioner training, there were no courses called “How to tell a patient she has cancer,” “How to tell a father his child has died,” or “How to tell a pregnant woman she has a sexually transmitted disease.” Breaking bad news is an on-the-job skill learned only in the doing, in the holding of patients’ hands, and in the simple comforting acts that suddenly erase the distance between nurse and patient: the hug that keeps someone on her feet; the way we sometimes let patients see the tears in our own eyes. In Intensive Care, I learned to deliver bits of stunning information as if they were updates from some distant, unfamiliar city. Calling a newly admitted child’s parent, I’d say, “Your son’s been admitted to ICU.” Then, I’d wait a few seconds Davis text.indb 63 11/12/08 10:00:35 AM 64  the heart’s truth for the implication in my voice to travel the phone wires. On the cancer ward, I perfected the arts of acknowledging the approach of death and staying with patients until death arrived. I’d grip a woman by the shoulders, look into her face. “I was with your husband when he died,” I’d say. “He didn’t go alone.” When I came to the women’s clinic, I thought joy would outweigh tragedy. Mostly, that’s true. But bad news here is particularly difficult to hear—it often involves new life, and it can pierce the soul. I’ve told mothers that their pregnancies won’t survive. I’ve announced that my fingers have palpated the solitary breast nodule that could be cancer. More and more often, I have to tell young women that their bodies are infected with diseases they get only from making love. How, I wonder, will Ellen react to the news that she has chlamydia? Some women nod and smile, unable to comprehend how they, who are faithful to their partners, could have a sexually transmitted disease. They look at me with such innocent bewilderment that I’m afraid for them. Then, when they finally understand, they weep or become so angry that even the bland, beige clinic walls seem unable to contain their fury. Other women blush and lower their eyes. They have secrets to tell, and sometimes they do: a brief affair; a man who, they thought, loved them. These women are dazed. They thought they were only following their hearts. When I say, “You’ll have to notify all your partners,” they feel abandoned. “How can I tell my husband?” they ask, or, “How can I tell my boyfriend?” I never have the right answer. Most often, patients receiving bad news crumble before me. Their skin blanches. They lose their breath, as if punched in the stomach. It’s difficult to watch their suffering. I’ve found it’s best to give bad news over time, bit by bit, like you’d give a child small bites of food...