bearer of bad news

ER docs often have to give bad news to patients and families. People die, they get injured, they develope potentially fatal diseases. In the dark ages of residency training, the 70's, we worked 36 hours on and 12 hours off. We made rounds with the senior residents and attendings and tried to learn how not to kill our patients. There was no training in how to handle death and dying. Yes I read Kubler Ross "On death and dying", but it didn't help. The old wisdom was to run the code behind closed doors and then to emerge with head hanging and say, "we did everything we could but your loved one died". The new paradigm is to have the family in the room. I accept this new approach but not with much enthusiasm. An experienced ER doctor knows by the circumstances of the arrest if the patient has any chance of survival and if so, with what, if any, degree of neurological recovery.
I was a witness to an unsuccessful cardiac arrest run by one of my younger partners. After the code was ended, a family member arrived who demonstrated a frequently seen behavior. The disbelieving loved one implores the deceased to wake up. Magical thinking? Frankensteinian reanimation? Early in my career I tried to resuscitate a 9 year old boy who had drowned. The nurses carefully cleaned up the detritus of the code and lovingly covered the body. Later, the father, an immigrant to the US arrived and after I told him the standard condolences and how hard we tried, he leaned over his son's body. Thinking that he was going to kiss his beloved child, I was rather taken aback when he scooped up the body, flung it over his shoulder and began jumping up and down. When I recovered enough to stop his bizarre behavior, the father told me that in his country, this was how you treated someone who drowned. Third world CPR. The father and I then shared a good cry over the boy's lifeless body.
The more challenging task of disclosure is to the patient who comes in for something he or she thinks is simple, a headache, a persistent cough, an annoying skin lesion, only to be told he has cancer. A patient who I saw recently came to the ER for cough and shortness of breath. Middle-aged and a smoker, I was thinking emphysema, chronic bronchitis, maybe even congestive heart failure. One chest x-ray, a chest CT, and some abnormal labs results proved that I would be giving a potentially terminal diagnosis to a fellow human being, who I had just met.
His Holiness John Paul II spoke of the dignity in the suffering of illness. I couldn't disagree more. I have run codes on patients who where dying on one or more terminal illnesses, but who the family or the family doctor had not made a DNR (do not resuscitate). Sometimes the problem is that the DNR paper work wasn't available. CPR is a degrading and brutal affair. Tubes are inserted into any available orifice, ribs and sternum crack like kindling with chest compressions, and the team tries to do their tasks without thinking to much about the dehumanization of the process. Years ago I treated an elderly man in congestive heart failure. His daughter was in the room. The patient was still a full code. I told this woman that the next step was entubation and placing her father on a ventilator. I asked if she thought her father would want to end his life on a machine. She told me to try and make her father comfortable but not to entubate or perform CPR. It was a relatively quiet night in the ER. It was shortly after my own father had died at home, with dignity, of cancer. I gave this gentleman some morphine and his daughter and held his hands and caressed his head as he took his last breaths. We both cried. I fulfilled my oath, Primum Non Nocere, first do no harm.