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Therapeutic Presence

At times a doctor does her best work by providing a therapeutic presence
Shannon Fagan/

Physicians have the unique duty of giving patients and their loved ones the worst news people can receive. It can be complicated, heavy, dark, somber, hopeless and often, in less-than-ideal circumstances (as if there are ideal circumstances for bad news.) It‘s as important as anything we will ever say or do with our patients.

Research shows that attitude and communication skills of the person delivering the bad news are important in determining the nature of a family’s grieving process, and in their ability to cope and recover. Empathy is essential, as well. I’ve made careful study of giving bad news and of communication in general in my professional and personal development. It’s a priceless investment.

These are two of the patients (or one patient and one patient’s mother) I recall to whom I found it especially difficult to give bad news. One was Tony – I had to tell him he had AIDS, long before there were treatments. [See Tony’s story on this site: “The Care of the Patient” – a Legacy, Feb 25, 2015.] Before he arrived, I mumbled and paced around the office. My staff made a few suggestions. My anxiety was in vain. Tony knew in his gut and heart why I’d called him to come in. We just sat in the exam room, with few words. We sat until Tony was done sitting – about 15 minutes. He didn’t need to hear any bioscience. He didn’t need to know the natural course of the disease. So, we just sat. That was just right for him that day. It’s called therapeutic presence (aka suit up and show up.)

The other patient was a 2-year-old boy. He arrived at the ER after a catastrophic motor vehicle accident. He was holding tight to life with his tiny hands, but his grip weakened. In a small room that no one wants to enter, there were at least 25 family members gathered around my small patient’s mother. I knelt next to her chair, eye to eye. I told her that we did everything we could, everything medicine had to offer, but it wasn’t enough; he didn’t make it. Many of his family were sobbing, including mom. I stayed by her side while the family began the process of grieving. I stayed by her side until she didn’t need me. I was her therapeutic presence. She didn’t need or ask for details. Mechanics and physiology and statistics were irrelevant.

Some, if not most, physicians feel that delivering bad news is one of the most difficult of their duties. Most have little training, if any, nor opportunity to build confidence in communicating bad news. We’re comfortable with curing and helping patients, which may make some physicians reluctant to discuss a diagnosis. Some physicians feel like failures if a cure is not possible. When under pressure, some physicians blurt out promises which are just false hope. That’s insensitive and can even be cruel.

Any of the reasons above, which a physician might use to rationalize avoidance of delivering bad news, are about the physician’s comfort. But it isn’t about us. It’s about the patients. My distaste for doing circumcisions doesn’t mean I can do it poorly or race through it. Giving bad news is as or more difficult, and potential consequences as great, as any procedure or physician duty.

An article I read in preparation to write this stated that time constraints, as well as the challenges of getting paid for these interactions, can become a burden. It has never occurred to me that time, or concern about getting paid for these encounters, would be something I experience as a burden. We all – patient, family, friends, and me become part of each other’s stories, however briefly. Sitting with the family by my patient’s bedside as s/he leaves earthly life is a great honor. It is not possible to overstate the family’s gratitude and relief that you are close. We tend to forget that to them this passage is unknown and intense, as real as life gets.

With the population aging, it’s to be expected that physicians will be facing more of these difficult discussions, including end-of-life care. There should be emphasis on understanding the social, psychological, and cultural contexts of our patients’ lives and the trusting relationships built with them over time. These relationships will help determine how and to whom you give difficult news and insight about how it will be received.

Communication doesn’t always require words. Much of what you say will be forgotten, but your presence will always be remembered. I have found that no matter the size of my giving to my patients and their families, they have already given me more.

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About Faith A. Coleman, MD

Dr. Coleman is a graduate of the University of New Mexico School of Medicine, and holds a BA in journalism from UNM. She completed her family practice residency at Wm. Beaumont Hospital, Troy and Royal Oak, MI, consistently ranked among the United States Top 100 Hospitals by US News and World Report. Her experience includes faculty appointments to a family practice residency and three medical schools, as well as Director of Women's and Children's Health Promotion Programs with the NE Texas Public Health District.

Dr. Coleman is the Expert on Gifted Children for the New York Times, parenting writer for Demand Media Studios, as well as health and medical writer for several online information services. She writes professional management material for health care providers and about the personal experience of being a physician. Faith treasures most the role of mother. Her passions include the well-being and education of children and families.