Giving Bad News: Accomplishing a Difficult Task
by Larry Czaplyski
Giving the bad news of a life threatening disease is never easy. Whether it’s telling a new patient that she has cancer, a regular patient that his liver is failing, or the parents of an eight year old that their child has leukemia, giving this kind of news is always difficult to do and even more difficult to do well.
Here’s how Mistie Joyce, an environmental professional in Los Angeles, CA, found out about her breast cancer: “A junior surgical resident came in after the biopsy and said that they’d found some cancer, and I should arrange an appointment in about a week when they’d have the pathology results back. Then he disappeared. Then at the appointment, he just said that they wanted to do a mastectomy as soon as possible – was this date OK…I was rushed into it when I may have had other options.”
Sherry Boyd, a CPA in Wichita Falls, Texas, had a similar experience. “My dad’s doctor was very cold. He said the words…but…with no inflection whatsoever…Dad had me and my mom with him at the time…I wanted to rip the doctor’s eyes out.”
Stories like these continue to happen more frequently than they should because doctors, like most people, feel uncomfortable in giving bad news. “When truth comes across as cruel or uncaring it is hardly ever because of the information itself but rather the way it is conveyed,” says Dr. Howard Brody, Director of the Center for Ethics at Michigan State University.
What follows are some ideas that can help you deliver bad news more effectively and compassionately. Keeping one or two in mind can make a big difference for your patients and their families during a very difficult time.
Preparing Yourself- the More Knowledgeable You Are, the More in Control You Will Feel
Be sure you understand the objective of the meeting. “The basic duty is to transmit the basic truth, so that the patient knows what follow-up questions to ask if he or she wants more information,” says Dr. Brody.
Take the time to think about the patient. Read the patient’s personal or medical history for information about family, religion, and cultural background. Find out who has permission to know the patient’s condition.
Review all medical information. Be thorough. If you’re one of several physicians treating the patient, check with the others to find out if anyone has given test results or other information to the patient.
Because it’s easy to lose track in an emotional meeting, make a short list of the points you want to cover. Realize that while the meeting may be difficult for you, what you will undergo pales in comparison to what your patient will experience.
Your Behavior – What’s Most Helpful to the Patient
Certain behaviors can make the meeting easier on your patient. According to Arthur L. Caplan, Ph.D., Director of the Center for Bioethics at the University of Pennsylvania, the most critical issue in delivering bad news is the “…manner of delivery including empathy, listening as well as talking,… treating the patient as a person – using the right name, sitting down, not looking at your watch…”
“From a research point of view, empathy is important because it has been shown to be one of the most salient factors accounting for “helping” in relationships,’ says Dr. Mack Lipkin, Director, Division of Primary Care, New York University Medical Center, Bellevue, NY, ‘From a psychological perspective, it shows the patient that one understands and validates his or her pain and suffering–therefore one feels less alone, less crazy or weak…”
Maintaining eye contact, touching the patient if appropriate, and reassuring the patient that’s alright to cry or express emotion are other important behaviors.
Preparing the Environment
Try not to give bad news over the telephone or to a patient in a clinical setting. While it may be tempting for you to get the telling over quickly, it’s no service to your patient.
Suggest that the patient bring a family member or friend along to the appointment. Bring along another doctor or a counselor. It’s not necessary that they speak.
If the patient doesn’t speak English, find a professional interpreter. Don’t use a family member. Dr. David Crippen at St. Francis Medical Center in Pittsburg, PA, recommends telling the interpreter to “…translate as accurately as possible the thought as well as the verbiage.”
Find a comfortable, quiet, and private place to talk. Make certain your beeper is off and ask your staff not to interrupt you during the meeting. It’s essential to set “…aside enough time to tell the patient and then be available to answer their questions,” says Dr. Bartolomew J. Tortella, Director, New Jersey Trauma & EMS Research Center.
Take care with seating arrangements. “My usual office setup is to sit at my desk with the patient in a chair right next to the desk facing me,’ says Dr. Robert S. Stall of Williamsville, NY, ‘I can hold a hand, touch an arm, offer a tissue, or make a phone call from this position.”
Preparing the Patient for the News
As you start the meeting, spend a few minutes establishing rapport. Ask the patient for permission to tape your discussion. This can be useful for the patient to listen to later.
Ask some questions to determine what the patient knows or guesses. “Most patients who do have a serious problem “know” that they do and for me to not acknowledge that would be a breach of our doctor-patient relationship. In fact, they might feel abandoned, let down, deceived and lied to,” says Dr. Stall.
As you see the patient is beginning to be aware of what is coming, find out how much the patient wants to know. “People and cultures vary on how much they want to know,’ says Dr. Thomas J. Smith of the Massey Cancer Center in Richmond, VA, ‘The only way to know what level of information is desired, and who should be given it, is to ask.”
Dr. Brody agrees. “Patients will tell us how much they want to know, and in what situation they want to be told, if we would take the time and trouble to ask them.”
Giving the Bad News
“Be honest and direct, and tell the patient that this is the way it is. They tend to appreciate truth and honesty far more than beating around the bush,” says Dr. Harvey Reich, Director of Critical Care Medicine at Rutland Regional Medical Center in Rutland, Vermont.
Dr. Stall concurs, “I have not found a patient that reacted in a way that I wish I had not told them. In fact, I am amazed at the strength people have when spoken to honestly. As I said, patients generally “know” something bad is wrong and are in a sense relieved when they know what it is.”
Give only enough information for basic understanding and immediate decision-making. “Enough medical information needs to be offered to support the situation, but too much can lead to confusion and misinterpretation,” says Dr. Reich.
Present what you see as the best and worst outlooks. “I do try to give the patient an idea of the most likely scenarios and how we will help them in each situation,” states Dr. Tortella.
After delivering the bad news, stop talking. “Just stay in the room, silently, and let the news sink in,’ continues Dr. Tortella, ‘avoid the tendency to keep talking, mostly to cover your own discomfort, and let the patient take the lead.”
Dr. Brody agrees, “The major flaw in most physician’s truth telling style is too much telling and not enough listening.”
Correct any misunderstandings. “Patients who do not understand their prognosis can make bad choices about what they want done…’ offers Dr. Smith, ‘…doctors are medically, legally, and ethically obligated to give patients enough information to make good choices. That standard is being redefined from doctor-driven to patient-driven.”
Give more information if the patient asks for more or if you need the patient to make an immediate decision. “Write down what is told,’ says Dr. Smith, ‘ask if they have enough information; if not, then ask what they need.”
Dealing with Initial Patient Reaction
The patient’s reaction is often one of anger, fear, and inner turmoil. In dealing with these issues, “It is important to be straightforward and not only avoid the use of euphemisms but also to be as caring and compassionate as possible,” says Dr. Tortella.
“I usually don’t cry, but my patients can see that I feel for them as a person and a friend, not just a bearer of information that can be as impersonal as a telegram or computer screen,” says Dr. Stall.
“Remember that the patient is the one with the disease,’ says Dr. Smith, ‘we cannot bleed for them, but we can share their emotions.”
Discussing Treatment Options
Address any immediate discomfit or medical requirements. Talk about all options. “In terms of informed consent, the doctor who addresses a non-curable patient and mentions only chemo or only hospice, without listing the options, has not fulfilled his or her responsibility for informed consent,” states Dr. Smith.
Dr. Stall agrees. “I always follow the news with possible approaches. They may include surgery, chemo, radiation or hospice care. I offer the pros and cons of each to the best of my knowledge or arrange a specialist consultation or I call a specialist, often right from my desk while they’re there, in order to get the best and most precise information for my patient.”
Give the patient information about support groups, counselors, and palliative-care resources. Let your patient know that you will answer questions about alternative treatments and provide names for second opinions.
“I also always emphasize that I will be there for them regardless of what choice of treatment they make, if they have any questions, or need someone to talk to,’ says Dr. Stall, ‘I encourage them to page me if it becomes particularly difficult for them to deal with things or if they have a pressing question.”
“There is no such thing as “no hope.” The patient may have any number of goals, some of which we cannot meet, some of which we can,’ says Dr. Brody, ‘listening is required to find out what the patient’s relevant goals are and then to offer realistic reassurance that we can help with at least some of them.”
“There is always hope, even if it is for a comfortable and peaceful dying experience, rather than for a cure, ’ says Dr. Reich, ‘the hope is that if there is no chance for life, that there will be no pain and suffering. This is a great deal of comfort for the patient and family.”
“There is hope for a symptom free existence. There is hope for making good choices, not dying from complications on a respirator or after CPR and there is always the chance for a medical or non-medical miracle outside of my realm. Always.” says Dr. Smith.
He continues, “But to say “Well, let’s try one last thing”, usually chemo, with no track record, known side effects, and no chance of meaningful help – that is not giving hope except false hope. It is subterfuge, and misleading to the patient unless you have given them all the options, and explained what you can and cannot do medically.”
Drawing to a Close
Close the discussion by inviting questions. Then summarize what you’ve told the patient and ask the patient if it’s accurate. Arrange for a follow-up review on the next day with the family present.
According to Dr. Smith, the basic message that a patient should take away from the meeting is “Here’s what I have, here’s what’s going to happen to me, here’s what they can and can’t do for me. There is hope for good care, taking account of my wishes for how I want to live my life.”
Dr. Tortella offers a similar observation about the message a patient should take away, “My days are numbered and I have to make the absolute most of the time left to me… my doctors will do everything to see that happens.”
“I always emphasize that I will be there for them regardless of what choice of treatment they make, if they have any questions, or need someone to talk to. I encourage them to page me if it becomes particularly difficult for them to deal with things or if they have a pressing question,” says Dr. Stall.
He continues “When they leave, I usually shake their hand firmly but sensitively, hug them or put my arm around their shoulder as appropriate to emphasize that I am there for them and to offer them some strength.”
After It’s Over
It is important to deal with the stress of the encounter before you see your next patient. For Dr. Tortella, this is a time to reflect on the meeting and “… try to take strength from the fact that I can continue to help the person through the time ahead.”
Dr. Reich believes it helps to keep in mind “…that the goal of helping the patient is not always by prolonging life. Helping in the dying process is help. In my experience, all families are extremely grateful for help and support in this.”