Breaking Bad News

I pick up the first chart. I'm about to flip it open to find out why this patient is here today when I see a note stuck on the front of the folder. "Positive for chlamydia" is scribbled in the secretary's handwriting. "Here for treatment."

I'm tempted to put the chart back and let one of the residents deal with this patient, but it's high-risk-pregnancy day and we're already backed up. Anyway, I've been a nurse practitioner in the women's clinic for more than 11 years – and before that, a nurse in intensive care and on a cancer ward. Giving bad news is part of my job.

Reviewing the chart, I read that the patient, Ellen, is in the 14th week of her first pregnancy. Three days ago, she'd experienced burning with urination and vague pelvic pain. She'd come to the clinic, terrified that something was wrong with her pregnancy. The resident who saw her collected a urine culture to make sure Ellen didn't have an infection and did a pelvic exam, checking for simple infections, like yeast, and culturing for more serious infections. Yesterday, the nurse called and left a message on Ellen's phone: "Come into the clinic tomorrow. We have your test results." Looking at the chart, I find that everything came back negative except the cervical culture. Ellen has chlamydia, a sexually transmitted disease; now I'm the one who must tell her.

Giving bad news to patients is a special talent, something no amount of education can teach. When I was in nursing school and, later, in nurse practitioner training, there were no courses called "How to tell a patient she has cancer," "How to tell a father his child has died," or "How to tell a pregnant woman she has a sexually transmitted disease." Breaking bad news is an on-the-job skill learned only in the doing, in the holding of patients' hands and in the simple comforting acts that suddenly erase the distance between patient and caregiver: the hug that keeps someone on her feet; the way we sometimes let patients see tears in our own eyes.

On the cancer ward, I perfected the arts of acknowledging the approach of death and staying with patients until death arrived. In intensive care, I learned to deliver bits of stunning information as if they were updates from some distant, unfamiliar city. Calling a newly admitted child's parent, I'd say, "Your son's been admitted to ICU." Then, I'd wait a few seconds for the implication in my voice to travel the phone wires. Or I'd grip a woman by the shoulders, look into her face. "I was with him when he went," I'd say. "He didn't go alone."

When I came to the women's clinic, I thought joy would outweigh tragedy. Mostly, that's true. But bad news here is particularly difficult to deliver; it often involves new life, and it can pierce the soul. I've told mothers that their pregnancies won't survive. I've announced that my fingers have palpated the solitary, fixed breast nodule that could be cancer. More and more often, I have to tell young women that their bodies are infected with diseases they get only from making love. How, I wonder, will Ellen react to the news that she has chlamydia?

Some women nod and smile, unable to comprehend how they, who are faithful to their partners, could have a sexually transmitted disease. They look at me with such innocent bewilderment that I'm afraid for them. Then, when they finally understand, they weep or become so angry that even the bland, beige clinic walls seem unable to contain their fury.

Other women blush and lower their eyes. These are the patients who have secrets to tell and, sometimes, they tell me. The brief affair. The man who, they thought, loved them more than their husbands. These women are dazed; they thought they were only following their hearts. When I say, "You'll have to notify all your partners," these women see themselves abandoned and alone. "How can I tell my husband?" they ask. I never have the right answer.

Most often, patients receiving bad news crumble before me. Their skin blanches. They lose their breath, as if punched in the stomach. It's difficult to watch their suffering. I've found it's best to give bad news over time, bit by bit, like you'd give a child small bites of food that are easier to swallow. Patients can only take in what they're ready to accept. Of course, bad news must be followed by a list of options, as if those might be the sips of water that help soothe the lump in the throat. If we can offer patients new tests, specialists to see, the possibility of cure, then we can also give them hope. After so many years in healthcare, I've learned that all we can really give our patients is what we would want for ourselves. We can listen without judging; we can accept that we are, after all, like our patients: stripped, raw, and vulnerable.

I take the chart and go into room four, where Ellen sits on the exam table. A man – I assume it's her partner – waits beside her on a chair. 'Oh,' I say to myself. 'This will be twice as hard.'

"Hi Ellen. I'm Cortney, a nurse practitioner here in the clinic." I extend my hand to her, then face the man. "Hi," I say. "And you are …?"

"Max," he answers.

"I got a message about test results," Ellen explains. "Is everything OK?" She rests one hand on her belly.

This exact moment – the uncertainty and possibility contained in the brief pause before I answer – is one of the things I dislike most about delivering bad news. Perhaps this is because I never plan what to say ahead of time, but wait until I can evaluate a patient's emotional reserve and then intuit how to proceed. Straight forward? With a maternal hug? Offhand and casual?

During this pause, I also feel guilty, as if I'm not simply a messenger but also somehow responsible for a patient's soon-to-be-visible anguish. I've learned that words are like stones. Tossed into the vast expanse of a patient's life, their impact causes shock waves. In ever-widening circles, everyone is affected. What was to be a patient's future is wrenched into a different shape and becomes, eventually, the past she'd like to forget. Sometimes, patients forever associate caregivers with the information we've delivered. I don't want to cause pain. Like any nurse or doctor, I want patients to like me.

A physician once told me that he "soft-pedals" the news, making a dire situation sound not so awful. He wants to spare patients pain, but I think evasiveness leads to confusion. I can't skirt the issues to avoid hurting a patient's feelings. At the same time, I want to be gentle. I know what it's like to have everything changed by a single test result or one damning word.

Ellen, even before I speak, looks hollow, as if the smallest blow could shatter her. Max looks anxious. I picture them raising their individual shields against anything that might alter their world.

"Ellen, I have your cervical culture results. Do you want Max to be here when we discuss them?"

I sit down by the exam table so I'm close to Ellen. After all, she is my patient. Part of me wants to say, "Tell him to leave. You might want to hear this alone." But there's another side of me, one I don't like, that wants to say, "Let him stay. Let him be devastated too."

"Yes, I'd like him to stay," she says.

I've never met Ellen before, not an uncommon occurrence in the clinic or in this era of managed care. In some ways, I'm glad. Being the messenger can be more difficult when I have a long-term relationship with a patient I've come to care about. In other ways, sometimes it's easier when I've treated a patient over time. Then when I arrive with disastrous results in hand, she knows I'll support her, that her misfortune will become our common grief.

"Ellen, your culture came back positive for an infection called chlamydia."

"Oh God. Is that something that could hurt the baby?"

"Not if it's treated, and we've caught it in time. I'll give you an antibiotic to take right after we talk. Your baby's going to be fine. And Max?" I turn to him. "You'll have to see your doctor and get treated too. It's important that you refrain from intercourse until you've both taken medication."

Max opens and closes his hands. I notice he's not wearing a wedding ring.

"I don't understand," Ellen says. "How did I get this?"

"Chlamydia is a sexually transmitted disease. You get it from having sex with someone who has it."

"But I only have sex with my husband."

"You get this infection when you have intercourse with someone who is already infected."

If I have to, I'll say this over and over. Bad news has to be given in short, strong sentences. Otherwise, it's impossible to hear. Even when it involves the simplest absolutes – he's dead; she has cancer – bad news takes time to understand. I see Ellen struggling: if she only has sex with Max, she caught this infection from him. If she has sex with other men, this could have come from any one of them. Once a man or woman has this infection, they can spread it to every partner they have.

The room is uncomfortably quiet. My pulse quickens. I want to make everything better. I could say, "It's very common – more than four million cases of chlamydia occur annually in the US," but that would be soft-pedaling, turning the attention away from Ellen's individual dilemma.

"I only have sex with Max." She looks at me as if I might shelter her from the image that, like a sudden eclipse, has darkened her imagination.

"Sexual intercourse is the only route of transmission." I place my hand on Ellen's knee. Tears fill her eyes and she purses her lips. When she goes to wipe her cheek, she begins to sob. I stand and put one arm around her, mindful of the newness of our relationship and the ambiguity of my role. I bring both the poison and the cure.

Max stands too. "I don't have any symptoms. I couldn't have given her anything."

"This infection might not cause any symptoms. That's why it's so difficult to detect."

"This means Max got it from someone else and gave it to me?" Ellen's face is blotchy.

"I don't know, Ellen. Chlamydia can be dormant in the body for months."

She speaks first. "We've been together three years," she says.

"Married for one," Max adds.

"Does that mean you've only been faithful to me for one?"

I don't interrupt.

"Tests can be wrong," Max says. He paces beside Ellen, who now holds both hands on her not-yet-enlarged belly, as if to cradle her fetus.

I say, "The type of test we use is rarely inaccurate." I'm accustomed to this back and forth rapid firing of questions. Such a debate always occurs as patients sort and assimilate the facts that accompany bad news. How did it happen? When did it happen? Are you sure? The last question patients ask, the one that I can never, ever answer, is why. Why did this happen? Patients think bad news might be easier to accept if only it came with some reason, some lesson, or someone to blame.

"We're having a baby," she says, half to me and half to Max. "How could you do this?"

"I didn't do anything," he says. "I could never do anything like that, and you know it. You know me."

I try to read his anger, then hers. Defensive? Honest? If I could ignore her embarrassment and his indignation, I might suppose they were the perfect couple. I never know which patients will someday become the recipients of bad news. You can't tell just by looking.

"I recently spoke to another couple with the same problem," I say. "They decided to trust each other – they both said they had no other partners – so they took their antibiotics and moved on. We have to treat this infection. But I know it's not as easy to heal the emotional effects."

In the grand list of bad news, some items are worse than others. I feel better when I can convince myself that bad news might also be the beginning of recovery, as I hope it will be for Ellen and Max. But in the end, grief is grief. It doesn't come neatly measured, and we can't compare one pain to another. There's nothing to be gained by telling a patient, "It could be worse." For Ellen and Max right now, this is grief enough.

I give Ellen four antibiotic tablets and watch as she takes them. I hand her a pamphlet about chlamydia. Max says, "Can't you treat me too?" and I tell him that this is a women's clinic. We don't treat men. He accepts this explanation but tips his head as if he hears something behind my words. Later, I'll replay our conversation. After all, I'm still trying to learn this technique, the best way to give bad news. Do I take sides? Even when I try not to, do I sometimes point a silent finger? Later, I'll wish I had a neat formula to follow. Then I'll think, …No.' Only we humans give and receive bad news. It must remain, therefore, a messy and imperfect skill.

In this case, I'll never know if the chlamydia test was falsely positive, if Ellen had another partner, or if it was Max who'd had a fling. One thing I know about bad news is that it often comes out of nowhere. Once it arrives, it never really goes away.

I shake their hands and say I hope I'll see them again. I ask Ellen to call me if she wants to talk or has any questions. When they walk out of the exam room and down the hall, Max takes Ellen's arm. She doesn't draw away.

We caregivers sometimes have allies when we give bad news – patients find information on the internet, and there are support groups for every ailment. Nevertheless, the initial announcement of bad news is always a solitary event, shared by patient and caregiver. When I'm the caregiver, all I can do is try to bring kindness, as well as truth, to the encounter: a hand's brief pressure, a silent standing by – anything that might help steady the heart.

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