For decades, the way bad news was broken was, as one official British report put it, “deeply insensitive”. Now we do it better, thanks to the efforts of one American widow. Sally Williams talks to her, and to policemen and doctors at the sharp end ...
From INTELLIGENT LIFE Magazine, Spring 2011
One winter evening in 1986, a police officer stood outside a home in north London, knowing he had to tell the woman inside that her husband was dead. Just 23, Jason Clauson was the newest recruit at the station, and therefore, by tradition, the one pushed into delivering the “death message”. “They’d say, ‘Come on lad, you’ve got to go and do it.’ If you objected, the governor would have gone, ‘Don’t be so stupid’.”
A few hours earlier, Clauson had been called to a roadside where a man in his late 50s had been found dead at the wheel of his car. It transpired that the man had taken early retirement and was on his way home from his last half-day at work, when he had apparently stopped because he felt unwell. Seconds later, he had a massive heart attack; the engine was still running when he died.
“He was sat there for three hours with the car overheating before someone noticed and started banging on the window, thinking he was asleep,” Clauson remembers. “By the time I got to the house, his wife was panicking because she’d called his office and they’d told her he’d left hours ago. So as soon as she opened the door and saw me, she knew something was wrong and she staggered on the doorstep. I reached out to grab her and her daughter got hold of her and said, ‘What’s wrong?’ And now they’re both saying, ‘What’s up? What’s wrong?’ Just bombarding me with the same question.
“I remember being told, ‘try and get them to sit down because if they faint [while standing up] they’ve got further to fall’, so eventually I got them to sit down. Basically I said, ‘I’m afraid I’ve got some terrible news for you. Your husband has passed away in his car.’ And you could see her world collapse. And you could see her daughter’s world collapse too. And I was sitting with my arm on the shoulder of two ladies thinking, what do I do now?”
Breaking bad news might seem straightforward. “It’s not rocket science,” said one surgeon I spoke to, “you’ve just got to be a half-decent person and give them the facts.” But common sense tells us that those facts are an emotional bomb waiting to go off. And medical thinking now recognises this: receiving bad news, according to the Western Journal of Medicine, “results in cognitive, behavioural, or emotional deficit in the person receiving the news that persists for some time after the news is received.” News of a sudden death can prompt intense crying, anger or guilt. Some people appear calm and controlled; others are seized by a need to be busy—faced with overwhelming pain, some of us block it by going and doing the washing-up. But no one in such a predicament can be considered normal. We go into shock, which means we are unbalanced mentally and physically. Distress impairs circulation, makes us cold, disrupts the endocrine, immune and cardiovascular systems, upsets rational thought, disturbs sleep.
Every year, 1.17m people die in road accidents around the world. As of January 2011, 7,066 soldiers from coalition forces had been killed in the wars in Iraq and Afghanistan, along with an estimated 110,000 civilians; in 2007, the last year for which there are full figures, 521,303 people died of cancer in western Europe. Behind all these statistics are families who need to be informed and someone whose job it is to inform them. There is now a widespread belief that the way the news is delivered has a profound effect on the way the dead person is remembered and the way the survivors heal.
There are some textbook examples of what not to do. Putting a note through the letterbox; getting the victim’s name wrong; using euphemisms such as “lost” or “passed on” (confusing at a time when someone is trying hard not to believe it); and turning up in shorts and flip-flops, like the British diplomats who greeted one woman as she arrived in Bahrain in 2006 after her husband’s death in a boat disaster. A vision that has stuck in her mind, rather than anything that was said.
And what of the bearers of bad news? What is it like to knock on a door knowing you are about to instigate the worst moment in someone’s life, and then have to confront the ways in which they do or do not deal with the fact that a life has ended? We live in an age where death has been largely exiled offstage. Families used to see it up close, at home; it did not typically involve hospital wards or dual carriageways or a stranger breaking the bad news. And there has been a slow realisation that unless the psychological particulars of that moment are addressed, unless the many challenges of grief and shock are dealt with competently, there can be unwelcome consequences. Which is why a number of fields have begun to wrestle with the problem: how do you break bad news in a good way?
Rob Cockburn sits in his office in London, opens his laptop, inserts a DVD and shows me how best to tell someone they’re dying. Cockburn manages Connected, a nationwide British programme to train oncologists in “difficult consultations”.
Launched in 2008, and funded by the Department of Health, it has so far trained 9,000 clinicians working with cancer on three-day courses using experts, actors and role play. The course is not voluntary: all cancer specialists in Britain are now expected to attend. This is the legacy of a shift in medical thinking. Thirty years ago, doctors believed that the dying didn’t want or need to know how ill they were. They disguised the truth in euphemisms (“just a little growth”) or restricted it to the patient’s family. Telling the patient, they believed, would take away all their hope. Even a decade ago, doctors felt quite anxious about telling people they had cancer and were going to die, so that news was often withheld from them.
In 2000, a report entitled Open Space was published by Macmillan Cancer Relief. “If only the surgeon would talk to me properly,” one patient said to the researchers. “They arrived in a group of five round my bed in hospital—and he talked quickly to me—he discussed something with them and moved on—I had no chance to ask questions...the surgeon gave me the impression he was busy big-time in front of his juniors—and not caring about my feelings...he is a clever surgeon but has a bad way with patients.”