Breaking Bad News: An Internal Struggle
There was a palpable sensation of exhaustion and anxiety as soon as I entered the room. I took one look at the chest X-ray and knew in my gut this was not going to be a normal echo. The heart was enlarged and taking up almost the entire chest. I sighed under my mask; this previously healthy newborn definitely had congenital heart disease, and I had to break the news to her parents.
I started asking the parents questions while examining the child, compartmentalizing and putting all my emotions aside. She was warm and pink with no murmur – but I knew something was wrong when her femoral pulses were absent.
I told the parents "I'm going to start the echo now. It will take about 30 minutes, and if I see anything concerning, I will let you know." I wanted to be honest with them. She had been transferred for cardiac evaluation, so I naively assumed it wouldn't be a complete shock if I gave them a diagnosis of heart disease. It only took four sweeps before the diagnosis was clear.
"I promised you both that I would let you know if I found something, and I want to be honest with you. I found a defect in your child's heart, and I believe it is the reason for her sleepiness and poor feeding. It is a serious matter, and I believe that she will require surgery to correct it."
"Oh, like a stent?" asked the mother.
"Well, a stent is more of a procedure. I'm referring to open heart surgery." I replied.
The mother burst into tears. The father attempted to assure her that surgery would simply solve the problem. I knew that the situation was far from simple. Although I was grateful that she did not have complex cyanotic heart disease, I was fully aware that this news would alter the lives of this family.
I felt incredibly guilty that I could not stop to console and educate the parents; I needed to continue obtaining data. Here was a new mother crying over her child, and there I was standing awkwardly taking more echo pictures and talking at her from the other side of the room. But I knew that I needed to gather time sensitive information about the baby's anatomy and cardiac function to make critical management decisions.
I wondered if I should have waited to tell them the diagnosis. I knew all too well the terrible feeling when medical staff mobilize around a patient and fail to inform their loved ones about the situation. I didn't want to inflict that upon these parents.
Once I completed the echo we sat and spoke in detail about her diagnosis, the surgery and what recovery entailed. I explained that she would be moving to the cardiac intensive care unit and she would not be able to go home until after surgery. I praised them for acting swiftly, seeking medical attention so quickly and trusting their instincts that she was not acting like herself, despite being only a week old.
The mother asked me, "Is there a chance that–I mean I know you can't say never–but could she…"
I replied "Are you asking if this is fatal? No. Because we are acting quickly, she has a great chance to regain her heart function and recover well from the surgery. I am optimistic that she will live a long life, play sports and can even have kids of her own one day."
As I spoke those words, I felt a twinge of discomfort. I can't predict the future; she could have a complication in the operating room and never recover. I knew the chances of that were very low, but I hate speaking in absolutes. Parents want to hear their child will be okay, but I always doubt if I have enough experience to say with certainty that they will.
As I left the room, I reflected on all the lessons we had in medical school on 'breaking bad news.' I used to build up these conversations in my head; scared of all the emotions it would bring and how uncomfortable it would feel.
However, as my fellowship comes to an end, I find that these conversations are becoming second nature and my associated anxiety and apprehension are decreasing. I now face the challenge of balancing my self-doubt with my medical expertise and providing accurate information while also reassuring my patients. This is a new kind of fear and anxiety; I hope it resolves as I enter the next phase of my career.
This article was authored by Priya Misra, MD, a third-year pediatric cardiology fellow at Children's National Hospital in Washington, DC.
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