Bearing bad tidings? Try these communication strategies
From the January ACP-ASIM Observer, copyright © 2003 by the American College of Physicians-American Society of Internal Medicine.
By Christine Kuehn Kelly
On her second day as an intern at Baptist Health System in Birmingham, Ala., Catherine Toms, MD, came on service and was notified by a nurse that a patient had stopped breathing. "The patient was DNR, and my attending wasn't present," she recalled. "I had to confirm the death and tell his wife."
Jeremy Abramson, ACP-ASIM Associate, had more time to get to know a patient who had stopped abusing drugs and had reconnected with his family after receiving a diagnosis of congestive heart failure. Then Dr. Abramson, a third-year resident at Massachusetts General Hospital in Boston, had to deliver more bad news: The patient had aggressive liver cancer.
"Working with patients in the last stages of dying has been the toughest experience in my training," he said.
There's no doubt about it: Delivering bad news to patients and family is difficult and stressful. Unfortunately, that discomfort can lead physicians to emotionally disengage just when patients need them most.
Bad news doesn't always mean a terminal diagnosis. In general, news is "bad" when it significantly alters a patient's view of the future, such as testing positive for a sexually transmitted disease or being diagnosed with a debilitating condition like osteoarthritis.
Sometimes, delivering bad news can make a bad situation radically worse. Residents report that family members have physically and verbally attacked them, threatened malpractice suits, fainted and needed stitches, and even had heart attacks upon hearing bad news.
"Sometimes it's a case of 'shoot the messenger,'" said one resident.
Still, giving bad news can help bring you closer to patients if done well. Here are some tips to help you deliver unwelcome news:
Prepare in advance. The best time to learn how patients feel about receiving bad news is before they need to hear it.
For example, you might ask a patient with a serious illness how much she wants to know if the condition doesn't improve. Often you can do this during a discussion about advance directives. Some residents ask seriously ill patients about their religious beliefs or their fears about being incapacitated so they can better understand their patients.
Get the facts first. As residents rotate through services, it is not unusual to be called on to give bad news to people you're meeting for the first time.
Phil Hemstreet, MD, chief internal medicine resident at Baptist Health System in Birmingham, Ala., said he gathers crucial information before the meeting. "I review the chart and ask the nurse if the death was expected, if the attending and chaplain were called, if the family was present during the death and how much they understood about the illness."
When he doesn't know the patient, he sympathetically acknowledges the need for someone more familiar with the case—such as the attending or family doctor—to explain things more fully. "However, in the case of a young person who dies unexpectedly, no preparation will alter the shock," Dr. Hemstreet said. "It's better to establish basic rapport and state the facts."
Take your time. As you learn more about a patient's condition through diagnostic testing, try to pass on information gradually. Orapitchaya Krairit, ACP-ASIM Associate, a third year internal medicine resident at MetroWest Medical Center in Framingham, Mass., said she gives news little by little to see how the patient copes.
For example, one of her patients with breathing problems presented with risk factors for both lung cancer and tuberculosis. As testing progressed, she and her intern communicated their concerns until the lung cancer diagnosis was definitive. "The communication process helped him cope with the final diagnosis," she said.
Pick a safe place. The hallway is not an appropriate place to tell a family about a loved one's terminal diagnosis. Find a quiet spot where you won't be interrupted and the patient and family can have some privacy.
Watch your body language. Sit at the same level as the patient and family, and maintain eye contact. Experts also recommend expressing empathy by touching the person you're speaking to on the arm or shoulder.
"A gentle touch is the most compassionate gesture," said Michelina Bonanno, PhD, a medical anthropologist and specialist in doctor-patient communication at Georgetown University in Washington.
Tell the truth. Studies show that most patients prefer frank, full disclosure of a terminal diagnosis or other bad news. Patients have the right to full disclosure, even if some family members may believe otherwise, especially when the patient is elderly. Gently let the family know the patient needs information about the condition.
Watch your words. Experts counsel against saying, "I know what you must be feeling." This trivializes the situation, Dr. Bonanno said. "No two people experience things the same way."
You should also avoid euphemisms. When words like "cancer" or "death" are part of the message, say so plainly to help make the information register. Don't wait too long in the conversation to use such words.
And don't rush to fill up silence. Giving patients and families time to process information shows that you respect their needs.
Keep in mind that what you say at this time will be remembered forever. Dr. Bonanno recalled a man who could repeat word for word what had been blurted out to him when his wife was told she had six months to live-some 30 years before.
Pursue concerns. Ask patients what worries them most. Although most patients faced with a terminal illness worry about pain, each patient will have unique concerns. Encouraging patients to discuss their feelings is more empathetic than simply stating your sympathy, Dr. Bonanno said, and helps patients begin to clarify and prioritize issues. Asking questions will also help you discover how much the patient understands about the diagnosis.
Watch for communication barriers. Different cultures have differing views of death and dying. Some elderly people may not understand a diagnosis, and interpreters may be necessary for non-English speakers.
Assess your patients' coping skills. Watch body language and emotional reactions. Patients who receive bad news often go through a grieving process, from denial and blame to disbelief, bargaining and acceptance.
Ask questions about the patient's family and home situation. And let the patient and family know about available support, such as online communities, palliative care experts, hospices, clergy and social workers.
Be accessible. Reassure the patient and family that you will be available for ongoing consultation as the illness progresses.
"I give some of my patients my cell phone number and tell them to call me anytime, day or night," Dr. Abramson said. Patients rarely make that late night call, but just knowing help is available strengthens the physician-patient bond and lowers patient stress.
Leave room for hope. Because no outcomes are 100% sure, it's important to mix hope with candor. Every patient and illness is unique. Some patients accept the inevitability of death, while others continue to fight to the end.
"Unexplained phenomena occur in medical science," pointed out Richard Frankel, PhD, professor of medicine at Indiana University School of Medicine in Indianapolis and senior scientist at Regenstrief Institute. "There's nothing wrong with saying, 'Anything is possible. We can hope for a miracle.'"
When an illness is likely to be terminal, orient your message toward how treatment can maximize quality of life and minimize pain. And don't define a tight time frame for the disease's progression. "No one is God and knows exactly when a patient will die," Dr. Bonanno said.
Summarize the news. Finish the discussion by reiterating key points, then ask patients to state what they heard in their own words. This can help patients move past their shock. Finally, clarify any issues that may still confuse them.
Take care of yourself. Often patients seek to minimize the pain their physician feels at having to give bad news. "Colleagues should provide the support you need, not patients," Dr. Frankel pointed out.
"We don't like to bring the office home," said Dr. Abramson, "but I find I can't put dying patients out of my mind." Residents should discuss their feelings with family and friends and seek help from colleagues, attendings or palliative care specialists.
When he was treating a patient dying of metastatic lung cancer whose family he was close to, for instance, Dr. Abramson sought support from the palliative care team leader. "We met to discuss the situation in a more directed way, and his words helped me manage my own feelings."
Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.
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