Since the coronavirus pandemic, emergency rooms across the country have been experiencing lower volumes and higher acuity.1
In my hospital, emergency physicians are now seeing more mental health crises, acute on chronic disease, and late stage presentations of new diagnoses. As the first New York coronavirus surge came to a lull in the late spring, recently, my C-word has not been COVID, but cancer. For the past few weeks, I have been diagnosing metastatic disease on nearly every shift - from pancreatic adenocarcinoma with hepatic invasion, to ovarian cancer with severe ascites, esophageal cancer with dysphagia, and thyroid cancer causing subglottic obstruction and stridor.
At the same time, cancer recently barged through my family's front door. Within minutes, our lives were changed. Priorities shifted. Expectations of the future paused. My family member's story is similar to so many of my patients' experiences. "I haven't been feeling well, but I've been too scared to see the doctor. I thought I wasn't supposed to come in..."
During the peak of the pandemic, many patients attributed their symptoms to coronavirus. Fevers - it must be COVID; back pain - probably viral myalgias; weight loss - perhaps deconditioning from quarantine. My relative did this too. As a result, his diagnosis was delayed. Now, I find my personal life paralleled in my professional life, causing me to reflect - what kind of doctor do I want to be in these moments?
Approximately 11% of new cancer diagnoses are ED-mediated.2 Historically, this disproportionately affects medically underserved patients with more advanced disease. As emergency physicians, we have unparalleled access to lab tests, EKGs, point-of-care ultrasounds, imaging, and consultants. Tests result in minutes to hours. Given our diagnostic power and breadth of knowledge, emergency physicians can diagnose diseases faster than most other fields of medicine. We can give patients answers the same day. But diagnoses carry weight. Due to the fast-paced work up, many patients are never warned of the possibility of cancer, which can make the news even more jarring.
Due to widespread clinic closures and patients' fear of exposure, COVID is possibly pushing even more of these new cancer diagnoses to the ED. Given the gravity of this diagnosis, it is important for all practitioners to develop a compassionate and deliberate approach when informing patients in the ED. The SPIKES3 approach (setting, perception, invitation, knowledge, empathy, and summary) lays the foundation for breaking bad news in medicine. Supplementing the SPIKES method, I have developed a framework for new ED cancer diagnoses. The purpose of the following section is to encourage all physicians to develop their own method for discussing new cancer diagnoses in the ED.
The radiology read. After reviewing the radiology images and impression, I strongly recommend discussing the case with the primary radiologist. Ask them what is the pre-test probability for cancer and what other diagnoses are on the differential. Print out a copy of the final radiology impression for the patient in case they are planning to follow up in a different hospital system. Give instructions on how to access medical records in case they would like the images as well. Most cancer patients are encouraged to seek second opinions during the treatment process so having a copy of these records will help streamline this process.
Scrub in. Treat breaking the news like a procedure and give it the respect that it deserves. Scrub in for it. The patient will always remember this moment, and their life is likely going to change after this conversation. Try to create a sterile field by minimizing distractions. Familiarize yourself with the basics and introduce yourself to family members. Try to assess: what are the patient’s values and level of health literacy. Make sure to communicate the radiology results. Before leaving a shift, you must ask yourself: does the patient know the suspected diagnosis? If not, who will tell them? What is the plan for when and how will this information be shared?
Open with a question. Elicit the patient’s understanding of their health, and how much they would like to know. This will give them an opportunity to share some of their fears. Simply asking, "What is your understanding of what's going on today?" can be a powerful question to gain insight into their health literacy.
Say "cancer."4 When explaining the radiographic findings, remember that there is no substitute for the word "cancer." Even the words "malignant," "metastatic," or "tumor" will not suffice. If cancer is high on your differential, you should communicate this possibility clearly while still leaving room for alternate diagnoses. It is important to emphasize that nothing is proven until the biopsy. Most patients will inevitably pepper you with questions about the staging, treatment plan, and prognosis, but try to remember your own limitations. Importantly, you can encourage patients to write down their questions for the specialist.
Read the room. Explore their emotions after receiving this news. Many patients will "black out" in the moment and forget most of the details. Convey empathy and mirror their moods. If your patient expresses interest in learning more, you can draw them pictures of the anatomy and use simple language to describe the disease. Consider sharing the radiology images with them and highlighting the concerning lesions. If your patient seems to be in shock, it is perfectly acceptable to remain silent. At times, I have walked away from the conversation to offer privacy for the family, given them a moment to process, and then returned with a glass of water to answer any further questions.
The follow-up. Oncologic work-ups take time, especially for final pathology results. The lag between a definitive diagnosis and initiating treatment can be anxiety-inducing, so encourage your patients to be expeditious in scheduling both a biopsy and follow-up care in a timely manner. You must secure close follow-up. If a patient is being admitted to the hospital, the inpatient teams will coordinate the oncologic work-up. However, if a patient is being discharged, consider their resources. A patient who regularly sees their primary care physician and is adherent with medications is vastly different from someone who has low health-literacy and rarely sees a doctor. Familiarize yourself with your hospital's resources, such as a rapid oncology clinic or breast clinic. If you are concerned, you can also call your affiliated oncologist to alert them of the new diagnosis and help coordinate outpatient management.
Compassion and hope are key. A cancer survivor advised me that just simply saying, "I'm sorry, this isn't fair, and I wish I had different news to share with you today," is often more appropriate than offering platitudes. Through intentional verbal and nonverbal communication, try to convey empathy and set the tone that physicians genuinely care. It is our honor and privilege to guide these conversations. Lastly, even with the grimmest diagnoses, always leave room for hope.
Take-Home Points
Between the fast-paced nature of the ED and shift changes, it can be easy to forget to inform patients of their diagnoses. Cancer is a life-altering diagnosis, so as emergency physicians we must develop a framework to convey this information clearly and compassionately, with the goal of securing timely follow-up.
References
- Hartnett KP, Kite-Powell A, DeVies J, et al. Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January1, 2019–May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:699–704. DOI: http://dx.doi.org/10.15585/mmwr.mm6923e1
- Rogers MJ, Matheson LM, Garrard B, et al. Cancer diagnosed in the Emergency Department of a Regional Health Service. Aust J Rural Health. 2016;24(6):409‐414. doi:10.1111/ajr.12280
- Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302‐311. doi:10.1634/theoncologist.5-4-302
- Hitoshi Okamura, Yosuke Uchitomi, Mitsuru Sasako, Kenji Eguchi, Tadao Kakizoe, Guidelines for Telling the Truth to Cancer Patients, Japanese Journal of Clinical Oncology, Volume 28, Issue 1, January 1998, Pages 1–4, https://doi.org/10.1093/jjco/28.1.1