Monday 25 February 2008


After starting to touch on the important difference between low mood that we all get through being human and experiencing emotion, compared to clinical depression, Lucy's comments got me thinking.

She posed 3 sensible questions about probity :

1) How straight talking are you allowed to be?
2) Have you told her that you are unwilling to prescribe medication because she is not clinically depressed, and that the reason she is unhappy is her situation (which only she can change)?
3) Are you 'allowed' to say things like this to patients?

How It Shalt Be

How to start? Well, let's see what our regulatory body, the General Medical Council have to say on this. This is important since basically the GMC get to say, "This Is How It Shalt Be, Or Mighty Shalt Be Mine Displeasure." They say, "Patients need good doctors. Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity."


So, to be a good doctor in the GMC's eyes, I have to be honest.

What if that's too hard, what if I didn't care about being a good doctor, I just want to be a good enough doctor, keep my head down and scrape by? Well in addition to the guidance on being a good doctor, the GMC also direct what the duties of a doctor are. These are neither optional nor negotiable.

Their publication, "Good Medical Practice" in 2006 says what must be done and what should be done by doctors.

"To justify that trust you must show respect for human life and you must: Be honest and open and act with integrity."

Right then, good doctors have to be open and honest, but so do bad doctors. Failure to do so is at variance with the GMCs direction on how doctors must conduct themselves.

Giving Information

That GMC document also states that I must, "Give patients the information they want or need in a way they can understand."

That's effectively two interesting clauses, there :
"Give patients the information they want in a way they can understand."
"Give patients the information they need in a way they can understand."

This is a must. Another directive that's neither optional nor negotiable. As a doctor I have to give my patients information that they want or they need. Therein lies the rub; there may well be situations where patients are being told what they need, which it not even close to being what they want.

Given that I must, "Make the care of your patient your first concern," I do it sensibly and professionally.

Sharing news as a process, not just as one event

When I trained as a GP I was lucky enough to work with excellent GPs who were passionate about good palliative care. I spent time in a hospice, too. Communication and sharing bad news was done very well.

Depending on who you believe, about 1 in 5 causes of dementia is thought to be due to Lewy Body disease. I think it's less but that's for another time. Patients with Lewy Body disease have a rough time, their carers have an equally rough time. Average duration from diagnosis to death : 3.5 years. If they're presenting later in the illness, obviously it's much shorter. When I first meet and diagnose someone with Lewy Body dementia, I don't paint things in such stark terms. The "honest" bit has to be tempered with some common sense. I don't duck it, if asked I'll share what I can, but on the first occasion when I give the diagnosis (which they almost all already know involves losing their memory, then abilities, then probably personality, then death) there's a place for support and explanation without adding excessive doom and gloom. As the condition progresses I talk through the different stages, the implications and what can be done so there is honesty and explicit discussion, but I do this over time. Will, undertaking two Lasting Power of Attorneys, driving, dentition, Council Tax, resuscitation if they have a cardiac arrest, end stage palliative care, lots is talked through. But not all in one go.

Sharing bad news is, in my experience, best done as a process. When I first get a referral I know little, I meet a patient and I'll introduce myself then explain why I believe we're meeting, clarifying something such as, "We're here because you went to your GP thinking you had memory problems."

After seeing them I'll have a feel for what's likely to be the case. I'll plan the biochemical, haematological and neuropsychological investigations to be undertaken and slant explanation accordingly, along lines of "memory problems" if delirium or treatable elements seem most likely, or raise the word "dementia" if it's seeming that that's the case.

When results are back, I'll continue to slant description in terms of what I think is going on, along with dropping in some comment on severity (mild, moderate, severe) since the neuropsych assessment will let me now quantify that. Usually I'll have a very good idea what's going on by now so I'll spell that out, such as, "I'm prepared to be surprised, but it does look as if it's likely to be dementia which has been caused by your high blood pressure, diabetes and frequent strokes."

After any radiological or radioisoptopic investigations we can then meet up and I can say, "Given the account you described, the course over the last blah months, the blood tests, the memory assessments and the imaging we did, the cause of your memory problems is blah." And then I go in to my spiel, then they have half an hour to ask questions, then at follow up they get to ask for further information.

To me, this process of being open at each stage makes the last stage effortless since you're simply confirming what you've already been honestly sharing with them over time already. Psychotherapists would say that I am, "socialising them to the idea," so it's not a shock when we have the final definitive discussion, sharing a diagnosis.


To answer Lucy's questions :

1) The GMC state that I have to be straight talking, but not ruthlessly so
2) I did explain why medication was not appropriate (which she'd already deduced but continued to hope wasn't the case)
3) I'm "allowed" to say whatever I wish, but I'm required to be professional and "make the care of [my] patient [my] first concern."


izzy said...

It's interesting to read about the way you break bad news. We had a tutorial on it not long ago and what you describe fits pretty much with that...prepare the patient, find out how much they know/want to know...give a warning shot... but I guess each case is still different It frightens me I must admit the thought of breaking bad news. I just wondered if you had any wee tips that you find helpful/patients find useful on breaking bad news?
ps. Thank you for the comments about the videos-i'm hoping it is useful and will try to get over the embarassment!

Am Ang Zhang said...

Some years ago in “Bangkok Hilton” Denholm Elliott said to Nicole Kidman, “Honesty is just an excuse to hurt.” It left quite an impression on me as it gives me a good excuse in some difficult situations. When I was at Queen Square, one of my tutors said: There is no “Motor Neuron Disease”. I was shocked at first. Then I realised that he wanted to impress upon us that no Brownie points would be awarded for being too smart and prematurely diagnosing a totally hopeless condition. This I have always remembered. Honesty is sometimes a tricky thing. Love your approach, Shrink.

The Cockroach Catcher

Ms-Ellisa said...

I really loved this post.

What you wrote is exactly what my teachers taught me about talking to patients with last stages of cancer or other fatal deseases...

It's a very great way of approaching the matter of the illness while in the same time respecting and caring for the patient.

Lucy said...

I don't think anybody has ever answered my questions quite so thoroughly!

Thank you, and an interesting read.
I can imagine that, although necessary, being honest could sometimes be a difficult thing.

PhD scientist said...

Great post, Shrink. Will be directing the students here next time this kind of subject comes up.

Dr Andrew Brown said...

Beautifully and compassionately argued.