Health Care's Moral Dilemma

There are all kinds of bad news in life.

You don't get into the college you want. Your girlfriend or boyfriend says, "We have to talk." Your boss says someone else is getting the corner office.

Then there is hospital bad news -- the life-and-death kind -- the kind that Rhonda Fishel has to deliver to patients in her care.

Fishel has been a surgeon for nearly 30 years at Sinai Hospital in Baltimore. She's given a lot of thought to the ways that doctors -- she and her colleagues -- tell patients some of the worst news they'll ever receive: that the doctors can't save them.

"The end of life is death -- even in America," Fishel said. "We all die, and bad news befalls all of us."

To Fishel, delivering bad news is an art in a medical world mostly ruled by science.

In a realm ever more dependent on technology and specialty, the common human touch may matter more than ever. Not every doctor has mastered it, though.

"For years I've had to give patients bad news, and I have thought a lot about how we do it," she said.

"There are days when you are very proud of how you interact with patients, and there are days when you are rushed or irritated and it may not be optimum."

When the Doctors Don't Break the News Gently

Lutricia Wolff, who is now one of Fishel's cancer patients, remembers how her first doctor broke the news of finding a cancerous lump.

"'It's cancer. I'll tell you that right now.' And I started crying. And he asked me, 'I don't know why you're so upset. You're small chested, anyway,'" Wolff said.

"I've had some cold, cold doctors," she said.

It may sound unbelievable, but Albert Aboulaifa says he's seen it since his earliest days as a resident.

Aboulaifa, also a surgeon at Sinai Hospital, described how one doctor casually smoked at the nurse's station when a distraught woman asked how her husband was doing.

"He had just taken the last drag off a short cigarette. … Dropped it on the floor [and said], 'He's dead.' I will never forget it," Aboulaifa said.

ABC News was standing by as Aboulaifa worked through a painfully tense bad news moment with a cancer patient named Leroy Jackson.

He had to tell Jackson about the cancer they had taken out of his body.

Aboulaifa thought he'd gotten all of it, but it was a more threatening kind than originally believed -- throwing Jackson a punch he hadn't expected.

"So is this going to take my life?" Jackson asked.

"It can, but I'm hoping it won't," Aboulaifa said.

Aboulaifa sat eye-to-eye with Jackson for the better part of half an hour, talking it through.

Perhaps it's not surprising that an already difficult task is even harder for surgeons.

There's a stereotype about surgeons that says they are particularly awkward at dealing with patients on a personal level -- the patients they're accustomed to dealing with are knocked out, asleep under anesthesia.

There's also the plain fact that most surgeons are so overworked and sleep-deprived just doing the surgery that sometimes they don't have much left for the intense emotional rigors.

Susanna Matsen, a resident at Johns Hopkins Hospital who studied under Fishel, offers another explanation.

"In the hierarchy of medicine, that's not how you advance. You don't get ahead by being able to give bad news well," Matsen said.

What Do Patients Deserve? Doctors' Best Practices

What does a surgeon owe a patient beyond a well-performed surgery, in terms of the human side of it?

What does a surgeon feel he or she really owes the patient? ABC News asked Fishel.

"I think that you really owe it to them to explain the information to them in a language that they can understand," Fishel said.

"And when it is really bad news … a setting where you have time for them."

What that means in practice can vary from person to person, but the doctors we talked to had concrete examples of methods they use, including ones that are simple and concrete.

Just making sure everyone is sitting down shows respect for the situation, Fishel said.

"Something as simple as handing someone a Kleenex is something that I have learned," Aboulaifa said.

There are also more subtle tactics, such as not telling people everything at once.

Dr. Matthew Stewart of John Hopkins Hospital explains one such scenario:

"You go in with your first session with the family and say, 'These are devastating injuries.' And then you stop there, and let people come to grips with that. And that lets you introduce in a later meeting, the ideas of how would this person like their end of life to be."

In short, it means understanding that not everybody is a "give it to me straight" kind of patient.

Hopeful, but Honest

Patients "want you to be hopeful, but they'd like you to be honest," Fishel said.

Not all doctors will meet that standard.

Not all patients have been told the bad news in a way that was best or easiest for them.

But meanwhile, Fishel has turned her passion about breaking bad news well into a mission.

"No matter where we go with technology, we always have to deal with something that can't be fixed, and a person that can't live forever," she said.

"To make that more comfortable for the patient and more bearable for the families has got to be one of our main priorities."

Rhonda Fishel can be reached at Sinai Hospital