Heath and Aging

Talking With Your Older Patient: A Clinician's Handbook

Breaking Bad News

At a Glance

  • Prepare yourself—allow enough time and have calls held.
  • Assess how much the patient understands and wants to know about the prognosis.
  • Be straightforward and compassionate.
  • Give the patient time to react.
  • Provide opportunities to continue the conversation in follow-up appointments or calls.

A couple holding hands, sitting across a desk from a doctorDelivering bad news is never easy, but tested strategies can ease the process. Knowing how to communicate bad news can also help you make the process more bearable for patients. For instance, try to break bad news in a compassionate yet direct way.

Prepare yourself. Before meeting with the patient, think about what you want to say and make sure you have all of the information you need. Be sure you have enough time to carefully explain the diagnosis and allow for questions, rather than trying to squeeze it between other appointments. If possible, ask your staff to hold calls and pages until the appointment is over. Find 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?"

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.

Spend a few moments finding out how much the patient really wants to know. People may have different expectations and preferences for how much they are told about their prognosis and what they 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, 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.

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 or offer false hope. 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.

Give the patient and family time—and privacy—to react. 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.

End the visit by establishing a plan for next steps. This may include gathering more information, ordering more tests, or preparing advance directives. Offer to write down important points of your discussion. Reassure the patient and family that you are not going to abandon them, regardless of referrals to other healthcare 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 and 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.

"I wish I had better news."

older womanDr. Callas has been thinking about how to tell Mrs. Larson she has Parkinson's disease. He doesn't want to feel pressured for time, so Dr. Callas makes sure Mrs. Larson has the last appointment of the day. Knowing that Mrs. Larson suspects something is seriously wrong, Dr. Callas decides the best approach is to be gentle, but direct. He reviews her chart for details, takes a deep breath, and opens the exam room door...

For more information on breaking bad news, contact:

American Counseling Association
1-800-347-6647 (toll free)
media@counseling.org
https://www.counseling.org/

This not-for-profit professional organization has resources to help inform patients and families of bad news.

Clinical Trials and You
1-301-496-4000
1-301-402-9612 (TTY)
www.nih.gov/health/clinicaltrials

This website from the National Institutes of Health explains the importance of participating in clinical trials and includes a list of registries, personal stories, resources for trial sites, and resources specifically for healthcare providers on referring patients to clinical trials.

Education in Palliative and End-of-life Care
Northwestern University Feinberg School of Medicine
1-312-503-3732
info@epec.net
www.epec.net

EPEC provides physicians the basic knowledge and skills needed to care for dying patients, including information about how to communicate bad news.

Publication Date: April 2016
Page Last Updated: April 6, 2016