Dr. Ron Naito, an internist in Portland, Oregon, was diagnosed with stage 4 pancreatic cancer in August 2018. His doctor wouldn’t confirm the terminal diagnosis, even though Naito read the test results and understood what they meant.
Patient communication

Never say ‘die’: Why so many doctors won’t break bad news

Following his own diagnosis of stage 4 pancreatic cancer, a physician is teaching others how to deliver life-altering news.

Editor’s note: This story was originally published by Kaiser Health News and has been edited for The DO with permission.

After nearly 40 years as an internist, Dr. Ron Naito knew what the sky-high results of his blood test meant. And it wasn’t good.

But when he turned to his doctors last summer to confirm the dire diagnosis — stage 4 pancreatic cancer — he learned the news in a way no patient should.

The first physician, a specialist Dr. Naito had known for 10 years, refused to acknowledge the results of the “off-the-scale” blood test that showed unmistakable signs of advanced cancer. “He simply didn’t want to tell me,” Dr. Naito said.

Be careful how you tell patients they’re dying

A second specialist performed a tumor biopsy, and then discussed the results with a medical student outside the open door of the exam room where Dr. Naito waited.

“They walk by one time and I can hear [the doctor] say ‘5 centimeters,’ ” said Dr. Naito. “Then they walk the other way and I can hear him say, ‘Very bad.’ ”

Months later, the shock remained fresh.

“I knew what it was,” Dr. Naito said last month, his voice thick with emotion. “Once [tumors grow] beyond 3 centimeters, they’re big. It’s a negative sign.”

The botched delivery of his grim diagnosis left Dr. Naito determined to share one final lesson with future physicians: Be careful how you tell patients they’re dying.

Since August 2018, when he calculated he had six months to live, Dr. Naito has mentored medical students at Oregon Health & Science University and spoken publicly about the need for doctors to improve the way they break bad news.

“Historically, it’s something we’ve never been taught,” said Dr. Naito, thin and bald from the effects of repeated rounds of chemotherapy. “Everyone feels uncomfortable doing it. It’s a very difficult thing.”

Dr. Naito cuddles his cat, Dolly, at his Portland, Oregon, home in May 2019. The poor delivery of Dr. Naito’s diagnosis with stage 4 pancreatic cancer left him determined to share his experience with future physicians. (Photo by Michael Hanson for KHN)

Why doctors struggle to break bad news

Robust research shows that doctors are notoriously bad at delivering life-altering news, said Dr. Anthony Back, an oncologist and palliative care expert at the University of Washington in Seattle, who wasn’t surprised that Dr. Naito’s diagnosis was poorly handled.

“Dr. Naito was given the news in the way that many people receive it,” said Dr. Back, who is a co-founder of VitalTalk, one of several organizations that teach doctors to improve their communication skills. “If the system doesn’t work for him, who’s it going to work for?”

Up to three-quarters of all patients with serious illness receive news in what researchers call a “suboptimal way,” Dr. Back estimated.

Too often, doctors avoid such conversations entirely, or they speak to patients using medical jargon. They frequently fail to notice that patients aren’t following the conversation or that they’re too overwhelmed with emotion to absorb the information, Dr. Back noted in a recent article.

“[Doctors] come in and say, ‘It’s cancer,’ they don’t sit down, they tell you from the doorway, and then they turn around and leave,” he said.

That’s because for many doctors, especially those who treat cancer and other challenging diseases, “death is viewed as a failure,” said Dr. Brad Stuart, a palliative care expert and chief medical officer for the Coalition to Transform Advanced Care, or C-TAC. They’ll often continue to prescribe treatment, even if it’s futile, Dr. Stuart said. It’s the difference between curing a disease and healing a person physically, emotionally and spiritually, he added.

“Curing is what it’s all about and healing has been forgotten,” Dr. Stuart said.

“You can’t prepare to die’

The result is that dying patients are often ill-informed. A 2016 study found that just 5% of cancer patients accurately understood their prognoses well enough to make informed decisions about their care. Another study found that 80% of patients with metastatic colon cancer thought they could be cured. In reality, chemotherapy can prolong life by weeks or months, and help ease symptoms, but it will not stop the disease.

Without a clear understanding of the disease, a person can’t plan for death, Dr. Naito said.

“You can’t go through your spiritual life, you can’t prepare to die,” Dr. Naito said. “Sure, you have your [legal] will, but there’s much more to it than that.”

The doctors who treated him had the best intentions, said Dr. Naito, who declined to publicly identify them or the clinic where they worked. Reached for verification, clinic officials refused to comment, citing privacy rules.

Indeed, most doctors consider open communication about death vital, research shows. A 2018 telephone survey of physicians found that nearly all thought end-of-life discussions were important — but fewer than a third said they had been trained to have them.

Dr. Back, who has been urging better medical communication for two decades, said there’s evidence that skills can be taught — and that doctors can improve.

“These are skills, doctors can acquire them, you can measure what they acquire,” he said.

Ask-Tell-Ask

For instance, doctors can learn — and practice — a simple communication model dubbed “Ask-Tell-Ask.” They ask the patient about their understanding of their disease or condition; tell him or her in straightforward, simple language about the bad news or treatment options; then ask if the patient understood what was just said.

Dr. Naito shared his experience with medical students in an OHSU course called “Living With Life-Threatening Illness,” which pairs students with ill and dying patients.

“He was able to talk very openly and quite calmly about his own experience,” said Amanda Ashley, associate director of OHSU’s Center for Ethics in Health Care.

Alyssa Hjelvik, 28, a first-year medical student, wound up spending hours more than required with Dr. Naito, learning about what it means to be a doctor — and what it means to die. The experience, she said, was “quite profound.”

“He impressed upon me that it’s so critical to be fully present and genuine,” said Hjelvik, who is considering a career as a cancer specialist.

Dr. Naito recently granted the center $1 million from the foundation formed in his name. He said he hopes that future doctors like Hjelvik — and current colleagues — will use his experience to shape the way they deliver bad news.

“The more people know this, it doesn’t have to be something you dread,” he said. “It can be a really heartfelt, deep experience to tell someone this, to tell another human being.”

 

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

 

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1 comment

  1. This article is very relevant and I hope that many physicians will read it and take it to heart. It was very real for me in 2001 as my father had stage 4 Pancreatic cancer with liver Mets and was diagnosed in about October and when he asked about the prognosis, he was told these up coming holidays will be your last, so you may want to consider that. My father a minister, and a hospital chaplain was mortified and called me, knowing that I work for DO’s, to ask if DO’s were trained in this fashion and he prayed that they weren’t. I called several times to speak to this physician, an MD and he refused to return my call or speak to me. (HIPAA was likely the veiled reason for no reply) I worked in an acute care facility in Cancer Registry for five years and spoke to many cancer patients at varying stages of disease for follow up and I was trained in the approach, to treat them as if they were a member of your own family. Training is key, compassion and empathy are required. Don’t let it be said about you as my dad said about his physician, “he was heartless”. Be well, and DO no harm.

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