How to Give Bad News

I know bad news is coming my way when my oncologist walks into the exam room with a nurse. It doesn’t matter that he introduces her as a new nurse getting to know the system. In my more than six years of seeing my oncologist for metastatic colon cancer, he has never come in accompanied. He wants her in the room to learn how to give bad news.

After 25 years as a pediatrician, I know the guidelines. Find a quiet room. Give the news directly. Allow for silences. Offer tissues and glasses of water. Wait for the family’s questions and answer them as fully as possible.

I’ve had to tell families that their child has a chronic disease, is gravely ill, has died. Now my oncologist rotates the chair facing the computer so it faces me. He sits down, makes eye contact, glances at the box of tissues by his side.

The nurse stands just behind him, shifting her weight between her feet. I sit on the exam table, with two of my friends next to me, holding my hands.

There are new liver lesions growing, my oncologist says. For years the lesions were dormant, encased in calcium. But the cancer cells have burst through their calcium borders. They are not yet wreaking havoc. My laboratory values and vital signs are normal. But the new liver lesions mean that the chemotherapy is no longer working.

I step out of my patient role and into my doctor role just long enough to acknowledge that my doctor is very good at giving bad news. He is asking what questions I have. He is allowing for silence. Tears are falling from my eyes, and he is silently handing me the box of tissues.

The nurse nods her head when he talks about the next steps. He will look into clinical trials and new medications. On Monday, he will meet with his colleagues to discuss my case. They will pull up images of my scans and discuss radiation, surgery, immunotherapy. Possibilities. The nurse nods, optimistic.

I look at the scans on my oncologist’s computer screen. He rolls the mouse to make the images bigger than life. He touches the light gray ovals of cancer on the CT scan and contrasts them to the darker gray of the rest of the liver. He points to the bright yellow sunburst-shaped spots of cancer on the PET scan—they stand out starkly against the purple-gray color of the rest of the liver. When I was a medical student, I thought those images looked like modern art. But not today. Today I know that those gray ovals and yellow spots are my growing cancer reacting to the contrast fluid infused in my body.

My oncologist cancels my chemotherapy for the day. While I wait to figure out the next steps, I will be full of uncertainty and fear of the growing cancer. But not having chemo means my next few days will not be full of nausea, diarrhea and exhaustion. No chemo means I will not need to go home and get under the covers.

The day opens up. Having cancer has taught me about patience and lack of control, and how to spend as much time as I can with those I love. I propose a hike with my friends. They say of course, and we drive the 10 minutes to Sleeping Giant State Park.

One friend chooses a trail I do not know. She says it will wind along the river before rising up the hill.

The trail gives us a good view of the trees that fell from the tornado a few years earlier. Some trees are dead, and others, whose intricate root systems have grown sideways and above the ground, seem to be regenerating. The day of the tornado was during a non-chemo week. I was driving my older daughter home through what was, in our town, just a bad rainstorm. I was not worried. I had no idea there was a serious storm brewing nearby.

We rest on a fallen log in a sunny spot. We talk of our children and partners and politics and cancer.

After our hike, we stop at the pharmacy to pick up passport photos. Last week, before my oncologist walked into the exam room with a nurse, my teenage daughters and I had the photos taken because our passports were expiring.

This week I wonder if I will ever leave the country again. I had hoped to have more adventures. I am confident that my daughters, just on the crest of their adulthood, will travel widely. At the cash register are extra-large chocolate bars. I buy two.

At dinner, my daughters are curious about how I had time to make dinner and why I am eating dinner with them. They know my typical chemo day has me napping all afternoon and into the evening.

I tell my daughters the news. I tell them I am on a chemo holiday because there are new cancerous growing liver lesions. The biggest collection of cells is 1.5 centimeters wide.

My daughters spread their thumbs and index fingers to estimate how big that is. It is small, they say.

We eat eggplant Parmesan and chocolate, and my daughters retreat to their rooms for homework and Netflix.

I have known for over six years that there would be lesions that would escape the clutches of chemotherapy. I am sad it is now. I had hoped for more time.

But there is no denial. I met the nurse who came into the exam room to learn how to give bad news. She, with her freshly pressed scrubs, will be better prepared to give the bad news next time.

Marjorie Rosenthal is a pediatrician at Yale.

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