We all know that veterinary medicine is not just puppies and kittens, and that from time to time we have to deliver bad news and have difficult conversations with clients. These conversations can be especially challenging and anxiety-inducing if they are unexpected.
For example, a few weeks ago my first appointment of the day was an 8 year old male neutered German Shepherd presenting for his annual wellness exam and vaccines. The owner did not report any concerns to my nurse — he had been eating and drinking normally, no notable changes in activity level or mobility, no vomiting or diarrhea or coughing or sneezing.
As I started my exam, I found that every single peripheral lymph node was extremely enlarged and firm…YIKES.
Here are 6 tips for veterinarians to make delivering bad news easier.
Tip #1: Take a deep breath while finishing your exam.
You know that what you are about to say to this owner is devastating. It’s very hard to effectively and compassionately communicate this type of information when your heart rate and anxiety are skyrocketing.
Take the time you are using to finish your exam to also take a few deep breaths before you start to tell the client what you’ve found.
Tip #2: Use an opening line that gently lets the owner know that you are about to share something that will be difficult to hear.
For example: “I’m so happy to hear that Bear has been doing so well at home lately, but I am seeing some changes on his physical exam that are concerning. His lymph nodes are all quite enlarged and firm.”
It may help to stop and show the owner and see if this is something that they had felt or noticed at home.
Tip #3: Be clear about your suspicions when talking about your top differentials to properly set client expectations.
“While we can see lymph node enlargement for a variety of reasons including infections, like with tick borne diseases, or with severe inflammation, given Bear’s age and how uniformly enlarged and firm his lymph nodes are, I’m more concerned that this may be a cancerous process like lymphoma.”
Tip #4: Provide your recommendations for investigating further.
“In order to definitively determine what’s causing Bear’s lymph nodes to be enlarged, we can take a fine needle aspirate of several lymph nodes to send out to the lab. This will tell us if his lymph nodes are reacting to something like an infection, or if we are seeing this because of lymphoma.”
“It would also be great to send some blood work to the lab to look for any systemic organ changes. Would it be okay if we did these things instead of his vaccines today?”
Tip #5: Provide some basic information on how you would proceed in the worst-case scenario, so that the client has an idea of what to expect when results come back.
“If Bear’s lymph node aspirates do come back definitively for lymphoma, we’ll have several options for treating Bear.”
“One option would be to consult with an oncologist and consider treating Bear with chemotherapy. While we all know that chemotherapy is hard on the body in humans, we use much lower doses in dogs so that they don’t face the same side effects.”
“Our goal is to give Bear as much good quality time as we can, not to cure the disease. There are different types of lymphoma and different chemotherapy protocols, and each carries a different prognosis. Usually, we can expect anywhere from 6 months to 1.5 years of good quality time depending on the type of lymphoma and the chemotherapy protocol that’s used.”
“If consulting with an oncologist and chemotherapy are not in the cards for Bear, we would treat him with steroids to provide him with as much good quality time as we can. Even though Bear is not showing any symptoms right now and he’s doing well at home, lymphoma that is treated with steroids alone unfortunately carries a prognosis of only 1 to 2 months.”
Tip #6: Acknowledge that what you are saying is difficult to hear and give the owner a few moments to process.
“I know that this is very unexpected and that was a lot of information. I’d like to stop here for a moment and answer whatever questions you have.”
Using these tips to communicate difficult news with owners, especially when it’s entirely unexpected, can help a hard conversation go more smoothly.
Setting up their expectations for the worst-case scenario also gives them some time to process while diagnostics are pending, and they are better prepared for the follow-up conversation the next day.