Delivering bad news is never easy, but tested strategies can ease the process.
"I wish I had better news."
Since Dr. Callas got Mrs. Larson's test results, he had been thinking about how to tell her she has Parkinson's disease. Because he didn't want to feel pressured for time, Dr. Callas made sure Mrs. Larson had today's last appointment. He knew she'd have a lot of questions. Knowing that Mrs. Larson suspected something was seriously wrong, Dr. Callas decided the best approach was to be gentle, but direct. He reviewed her chart for details, took a deep breath, and opened the exam room door...
Knowing how to communicate bad news can help you to make the process more bearable for patients. The Education in Palliative and End-of-Life Care Project (EPEC), www.epec.net , offers a module, "Communicating Bad News," that provides a practical approach. It indicates that breaking bad news in a compassionate yet direct way can help physicians and patients. And, although some of the advice may seem obvious, it may also be the sort of thing that is easily overlooked.
The first step is to prepare yourself. Before meeting with the patient, think about what you want to say and make sure that you have all of the information you need. Be sure there is enough time, rather than trying to schedule it between other appointments. If possible, ask your staff to hold calls and pages until the appointment is over.
You may feel more comfortable by first finding out what the patient knows about his or her condition. You might ask questions such as, "Have you been worried about your illness or symptoms?"
Next, you might spend a few moments finding out how much the patient really wants to know. Depending on their cultural background, personal history, or medical status, people may have different expectations and preferences for what they should be told. You might ask the patient if he or she wants to hear the prognosis, for example, or would prefer not to know.
If a patient's family has reservations about having the patient know the prognosis, you might ask them about their concerns. Legally, of course, you are obligated to tell the patient; however, you may negotiate some elements with the family. If you cannot resolve it, an ethics consultation may be helpful.
When you are ready to share the bad news, try to be as straightforward as possible, without speaking in a monotone or delivering a monologue. Be positive, but avoid the natural temptation to minimize the seriousness of the diagnosis. Communications experts suggest that you not start by saying, "I'm sorry . . ." Instead, try saying, "I feel bad to have to tell you . . ." After you have explained the bad news, you can express genuine sadness while reassuring the patient that you and others will be there to help.
Of course, people will respond differently to bad news; shock, anger, sorrow, despair, denial, blame, disbelief, and guilt all are common reactions. In some cases, people may simply have to leave the office. Try to give the patient and family time—and privacy—to react.
A good way to end this visit is to establish a plan for next steps. This may include gathering more information, ordering more tests, or preparing advance directives. Reassure the patient and family that you are not going to abandon them, regardless of referrals to other health care providers. Let them know how they can reach you—and be sure to respond when they call.
In follow-up appointments or conversations, give the patient an opportunity to talk again about the situation. Ask if he or she has more questions or needs help talking with family members or others about the diagnosis. Assess the patient's level of emotional distress and consider a referral to a mental health provider.
The Language of Bad News: Phrases That Help
These phrases can help you to be straightforward, yet compassionate:
Delivering bad news
- "I'm afraid the news is not good. The biopsy showed you have colon cancer."
- "Unfortunately, there is no question about the results. You have emphysema."
- "The report is back, and it's not as we had hoped. It confirms that you have the early stages of Parkinson's disease."
Responding to patient reactions
- "I imagine this is difficult news."
- "Does this news frighten you?"
- "I wish the news were different."
- "Is there anyone you'd like me to call?"
- "I'll try to help you."
- "I'll help you tell your children."
Dealing with prognosis
- "What are you expecting to happen?"
- "What would you like to have happen?"
- "How specific would you like me to be?"
- "What are your fears about what might happen?"
Adapted from: Emanuel LL, von Gunten CF, Ferris FF, and Hauser JM, eds. "Module 2: Communicating Bad News," The Education in Palliative and End-of-Life Care (EPEC) Curriculum: © The EPEC Project, 1999, 2003.
Referring Patients to Clinical Trials
Carefully conducted clinical trials are the primary way researchers find out if a promising treatment is safe and effective. Patients who participate in clinical research can gain access to new treatments before they are widely available and help others by contributing to medical research findings. Clinicians have an important role in continuing to care for patients who participate in clinical trials. Most trials offer short-term treatments related to a specific illness or condition. They do not provide extended or complete primary health care. You will continue your involvement in the patient's care but may need to communicate at times with your patient's clinical research team. By working with the research team, you can ensure that other medications or treatment needed by your patient will not conflict with the protocol.
For information about federally and privately supported clinical research, visit: www.clinicaltrials.gov .
- Prepare yourself for delivering bad news—allow enough time, and have calls held.
- Find out how much the patient understands and how much he or she wants to know about the prognosis.
- Be straightforward and compassionate.
- Give the patient time to react.
- Establish a plan for next steps; let the patient and family know you are not going to abandon them.
- Give the patient an opportunity to continue the conversation in follow-up appointments or calls.