5 giving bad news

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Giving Bad News~~Geoffrey H. Gordon, MD

INTRODUCTION

A debilitating or terminal illness, a catastrophic in-jury, death-these are situations both patients andph ys ici an s f ac e. an d the y ar e al l si tu at io ns in whi chthe physician must break the news to patients , par t-ners , and family members. The following sections of this chapter use a diagnosis of cancer to illustratesome general pr inciples that can help physicians inthis task. Despite these su, ,oestions however , there isno one right-or easy-way to present bad news.

Most physicians now inform cancer patients of

their diagnosis. This trend to near-universal disclosureis the result, in part, of greater public awareness of ad-vances in cancer diagnosis and treatment. greater pa-tient autonomy and self-determination, and greater

physician collaboration with patients to decrease theirisolation and fear and to mobilize their resources and

coping skills . Self-report surveys of cancer patientssince 1950 suggest that physicians have always un-derestimated patients desires to know their cancer di-agnosis and prognosis .

One might expect that the content of the bad news isoverwhelmingly more important than the process withwhich it is delivered. This does not appear to be thecase. Patients usually have vivid recall of the physi-

cians manner and style but need repeated explanationsof the facts. For example, the way that parents are toldthat their child has a developmental disability or men-tal retardation affects the emotional state and attitudesof both child and parents. These parents can distinguish

the message from the messenger, and one-third to onehalf are dissatisfied with how they were given the news.

TECHNIQUES FOR GIVINGBAD NEWS

A systematic approach to giving bad news (Table 3-l)can make the process more predictable and less emo-tionally draining for the physician. The process of giving

bad news can be divided into six categories: preparation.setting. delivering the news, offering emotional support,

providing information, and closing the interview.

Terminal or Catastrophic I l lnessPreparation: When cancer is a s trong diagnostic

possibi lity. consider discussing it with the patientearly in the work-up:

DOCTOR: That shadow on your x-ray worries me. It

could be an old scar, a patch of pneumonia, or even a

cancer. I think we should do some more tests to find out

exactly what it is. That way, well be able to plan the best

treatment.

Plan ahead with the patient about how he or shewould like to receive the news:

DOCTOR: Whatever the biopsy shows, 111 want to ex-plain it carefully-is there someone youd like to have

with you when I go over this?Knowledge of the patients pr ior reactions to bad

news can be useful-but not necessar ily predictive of the patients response. Ideally, pr imary and specialis tphysicians should decide in advance who will giveba d ne ws an d ar ra ng e fo ll ow -up .

Setting: Although it is always best to give bad

news in person. if the patient is unable to come to theoffice and asks for the diagnosis over the phone, it isbe st no t to l ie . In st ea d, be gi n a di al og ue th at pr ov id esba si c in fo rma tion :

DOCTOR: The biopsy showed a type of lung cancer.

The dialogue should conclude with a request tocome to the office soon for fur ther discussion:

DOCTOR: As soon as you can come in, Ill be able to

tell you more about what we need to do next.

Always take responsibility for deliver ing bad newsyourself. Find a private place to talk with patients.

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16 CHAPTER 3

T ab l e 3 - l . T e c h n i q u e s f o r g i v i n g b a d n e w s .

Category

P r e p a r a t i o n

Technique

F o r e c a s t p o s s i b i l i t y o f b a d n e w s .C l a r i f y w h o s h o u l d a t t e n d t h e b a d

n e w s v i s i t .C l a r i f y w h o s h o u l d g i v e t h e b a d n e w s .

S e t t i n g G i v e b a d n e w s i n p e r s o n .G i v e b a d n e w s i n p r i v a t e .

S i t d o w n a n d m a k e e y e c o n t a c t .

D e l i v e r y I d e n t i f y w h a t t h e p a t i e n t a l r e a d yknows.

G i v e t h e n e w s c l e a r l y a n d u n a m b i g u -ous ly .

I d e n t i f y i m p o r t a n t f e e l i n g s a n d

conce r ns .

E m o t i o n a l S u p p o r t R e m a i n w i t h t h e p a t i e n t a n d l i s t e n .

U s e e m p a t h i c s t a t e m e n t s .I n v i t e f u r t h e r d i a l o g u e .

I n f o r m a t i o n U s e s i m p l e , c l e a r w o r d s a n d c o n c e p t s .

S u m m a r i z e a n d c h e c k p a t i e n t s u n d e r -s t a n d i n g .

U s e h a n d o u t s a n d o t h e r r e s o u r c e s .

C l o s u r e M a k e a p l a n f o r t h e i m m e d i a t e f u t u r e .

A s k a b o u t i m m e d i a t e n e e d s .S c h e d u l e a f o l l o w - u p a p p o i n t m e n t .

Patients in examination gowns should have the oppor-tunity to dress before receiving bad news. Sit down at

eye level and give them your full attention and concern.Delivering the News: The next s tep is test the

patients readiness to hear the news. Review the work-up to date:

DOCTOR: You know we saw that shadow on your chest

x-ray. When we did the CT scan of your chest. we saw a

mass in your lung, and then we looked down your wind-

pipe and took a small sample of your lung. We have the

results of that biopsy now.

Remember that most patients will have consulted aninformal health advisor (a family member, book. orneighbor) at some point during the illness and willhave already developed an illness model or cogni-tive map of what is wrong. what it means. and whatcan be done. It is useful to elicit this model because the

clinician can correct the patients misconceptions andalso put the explanations into a context with which the

patient is already familiar. To elicit the model. askabout the patients understanding and concerns:

DOCTOR: What do you already know about this? What

concerns you the most about it?

Allow for silence during the conversation, espe-cially as emotions set in. Avoid lectur ing about thedisease, workup, and treatment. While detailed infor-mation is familiar territory for physicians and helpsreduce their own anxiety, it is rarely helpful for pa-tients who are hearing bad news for the f irs t time.

Some patients will immediately ask if the diagnosis

is cancer and want to be told promptly and directly.Others will tell the physician, verbally or nonverbally,to go more slowly. There are at least two ways to slowdown the message: To grade the exposure and to pre-sent the hopeful news f irs t.

1. Grade the exposure. Begin with an introduc-tory phrase that prepares the patient for the bad news:

DOCTOR: Im afraid I have bad news for you. . . . This

is more serious than we thought. . . There were some

cancer cells in the biopsy.

The main challenge with this approach i s to f in ishwith a clear , unambiguous s tatement that the patienthas cancer.

2. Present the hopeful message first. Thistechnique is based on the fact that patients rememberlittle of what they are told after the bad news is given:

DOCTOR: Whatever I tell you in a moment, I want you

to remember that the situation is serious, but theres

plenty we can do. Its important that we work closely to-

gether over the next several months. Im sorry, but your

tests were positive for a type of lung cancer.

Once the news sinks in, the patient will typically re-act with a mixture of emotions, concerns, and requestsfor information and guidance. Spend a few momentson feelings and concerns before giving more informa-tion. or patients may be unable to hear and assimilate

it. Explore the or igins of these feelings and concerns,be ca us e th ey ma y ar is e fr om mi sc on ce pt io ns ba se d onexperiences with fr iends or family.

Offering Emotional Support: Getting badnews is pr imarily an emotional rather than a cognitiveevent. Common. immediate emotional reactions arefear , anger , gr ief , and shock or emotional numbness.An important challenge for many providers is to re-main present with patients having strong emotionalreactions and to tolerate their dis tress . There are nomagic words or r ight thing to say. Sit near the patientand use empathic s tatements:

DOCTOR: I can see this is a terrible blow for you. I cant

imagine what it must be like. I want you to know that Illcontinue to be your doctor and work with you on this.

Many patients f ind a touch on the hand or shoulder to be supportive and reassuring. I t is also helpful toask unaccompanied patients if there is anyone whoshould be called af ter they receive the news.

Some patients direct anger at the physician:

PATIENT: Youd better check again-you doctors are al-

ways making mistakes!

or

PATIENT: Ive always come in for check-ups; why

didnt you find this sooner?

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GIVING BAD NEWS 17

Rather than becoming defensive. the physicianshould acknowledge that many people in this situationfeel cheated and an ory It is important to emphasizethat the disease. not the doctor , is the enemy and thatdoctor and patient must work together to fight it.

Patients who are very businesslike or too stunned tocommunicate their feelings are hard to evaluate be-cause the degree of dis tress is not always obvious.They may express their gr ief alone or want to be withothers, such as a friend or minister, before sharingtheir feelings with a doctor. The physician can ac-knowledge the diff icult nature of the news and legit-imize future expression of feelings:

DOCTOR: I know this is hard to believe. You may have

some feelings about it later that youd like to talk withme about-Im always ready to listen.

Providing Information: Patients of ten want toknow whether they really have cancer, if it has spread,if it is treatable or curable, and what treatment will in-volve. Some patients also want to know whether theyare going to die and, if so. how much time they haveleft. Even with careful explanations, many patientsare unable to assimilate much information at the timethe bad news is given. Effective educational strategiesinclude using simple, clear words; providing inforrnation in small, digestible chunks; summarizing andchecking the patients understanding of what has beensaid; and using handouts or other resources.Questions should be answered directly and honestly:

DOCTOR: There are statistics on how long people with

this condition are likely to live, and I can share them

with you, but they are just averages. No one can say for

sure how long you will live.

Closing the Interview: Most patients, evenwhen initially distraught, compose themselves

quickly with support and direction. The most effectiveway to reach closure is to provide a plan for the im-mediate future. This includes asking patients who elseneeds to know the news and if they want help sharingit. I t is important to reassure patients that the physi-

cian will still be their doctor even though they willneed to see consultants and have further testing. A fol-low-up appointment should be scheduled within thenext several weeks, and patients should be asked towrite down questions and concerns that they or their families have between visits. Ask about immediate

pr ob le ms su ch as an xi et y, de pr es si on , or in so mn ia.While some physicians like to prescribe a short courseof medication for s leeplessness or anxiety, patientsshould also be told that it is normal to feel upset or tohave trouble s leeping af ter receiving bad news.

DeathSome additional considerations apply when notify-

ing family members of the death of a loved one (see

Chapter 35). Unexpected or traumatic deaths are oftenthe most diff icult because survivors are unpreparedand rarely have a pr ior relationship with the notifyingphysician. Physicians should begin by identifyingthemselves and their role in the deceaseds care.Survivors who must be reached by telephone should

be told to come to the hospital prior to the actual deathnotif ication. unless they specif ically ask about death.

Once given the news, survivors may want to viewthe body. This is an important part of the grieving

pr oc es s an d sh ou ld no t be di sc ou ra ge d. Su rv ivo rs ar eoften concerned about whether their loved one suf-

fered or was alone at the time of death and whetherthey could have done anything to prevent it . They canoften be told truthfully that the patient was uncon-

scious prior to death, there was no evidence of suffer-ing, and that maximal efforts were made to help.People also may need to be reassured that none oftheir actions hastened the patients death.

Depending on the cause of death and comorbidconditions. the deceased may be a candidate for organdonation. Although some families object, many othersf ind comfort in making an anatomic gif t. Many statesinquire about and record anatomic donor permissionon drivers licenses, and families may discover thatthe deceased did, in fact, give such consent.Permission for autopsy can also be requested at thistime. Once the notifying physician has brought upthese topics, many hospitals have specially trainedstaff to work further with families. Some hospitalsand physicians routinely send sympathy cards ormake follow-up calls to recently bereaved survivors .

PROBLEM AREAS

AcceptanceDont Tell Me if Its Cancer: Some patients

specif ically request not to be told that they have can-cer. The physician should ask these patients what badnews would mean to them, or what they are afraidmight happen if they were given bad news.

When patients ask not to be given bad news, it isimportant to explain the rationale for their knowing

the diagnosis:

DOCTOR: Your job is to create the best environment for

our medicines and treatments to work. This includes

working with us to plan your treatment, finding which

parts of you are healthy and strong, and which areas still

need some work. Your attitude and interest are important

parts of your treatment; they may help you feel better,

and in some cases, the treatment may work better. We

want you to ask questions about what is happening-re-

member that there are no stupid questions. If it would

help you to talk with someone who has been through

this, please let me know.

Dont Tell Him or Her Its Cancer: Familymembers may ask that patients not be told the diag


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18 CHAPTER 3

nosis of cancer. Families should be thanked for theirconcern and reassured that information will not beforced on the patient. They should also be told that pa-tients questions will be answered truthfully. Explainthe rationale for patients knowing the diagnosis, andhelp families find w a ys to provide emot ional suppor t .Some families will find this difficult because of priorexperiences with bad news. Consider eliciting thefamilys concerns about what might happen if the pa-tient knows. It may help to approach patients with thedilemma:

DOCTOR: Your family has told me that youd prefer not

to be informed about some important aspects of your

care-what are your thoughts about this?

Such an approach can facili tate further discussionwith the patient and family.I Dont Believe Its Cancer: Some patients are

unable to accept the diagnosis, offering such state-ments as I just know it isnt cancer. If I can get somerest Il l be fine. This is most frustrating when it de-lays the early implementation of potentially curativetreatment. Physicians often use logical arguments anddire predictions to persuade patients to agree toworkup and treatment. Paradoxically, this approachmakes many patients more resistant. Instead, the

ph ysi ci an sh ou ld tr y to de pic t den ia l as a so me ti me suseful, but currently maladaptive. way of coping. Thiscan be done by explainin, that patients are often oftwo minds:

DOCTOR: Many patients find this kind of diagnosis

hard to believe. I can see that part of you wants to look

on the bright side and stay hopeful. but I wonder if you

dont also have times when you realize that problems

might arise. Lets think about how to proceed if the di-

agnosis is more serious.

The physician should offer to answer any futurequestions the patient might have and expect day-to-day variation in the patients abili ty to acknowledge

the accuracy of the diagnosis. Conversations shouldbe do cu me nt ed in th e pa ti ent s cha rt to no ti fy ot he rsof the patients reaction. Sometimes anticipating fu-ture needs helps patients accept the reality of the di-

agnosis :

DOCTOR: Lets take a few minutes to think about your

plans if your condition worsens, You may want to make

decisions and plans now. in case youre unable to handle

them in the future.

Different Cultural ValuesPIttnudes and beliefs about bad news. death. andthe expression of grief are determined in part by cul-tural norms (see Chapter 13). For example, in someAsian cultural groups, bad news about health-relatedmatters is routinely withheld from patients. In someEthiopian cultural groups, the delivery of bad news to

pat ie nts i s a pro ces s th at inv olv es the wh ol e fa mi ly .There are also cultural differences in responding todeath: such rituals surrounding patient death as open-ing windows and burning candles may be difficult toaccommodate in an acute care sett ing. Cultural differ-ences between physicians and patients and their fam-ilies become problematic when they are not recog-

nized as such and are attributed to patient or familyuncooperativeness or psychopathology. Physicianswho were born and raised in a cultural group with be-havioral norms that differ from those in the system inwhich they are training or working may find such dif-ferences hard to reconcile and may experience roleconflicts in caring for patients and families from theirown culture. In this case, consultation with a col-league whose background is outside the subculture

may lend some objectivity.

HOPE REASSURANCE

Patients and families are fearful of losing hope.Unfortunately, many physicians have never learnedhow to offer hope and reassurance along with badnews. To physicians, hope and reassurance bring tomind cure. prolonged survival or. at the very least. tu-mor response. To patients and families, hope may ini-tially mean cure but later can mean reconciliationwith friends or family who have been estranged. orthe opportunity to finish projects, find new sources ofself-esteem. see a next birthday or family event. l ive

without pain, or spend valuable t ime with loved ones.There are several ways physicians ca n pr ov id e hop e

and reassurance at the t ime of bad news:

Use positive words. Recognize the difference be-tween the uncertain perception of Your scan isnegative and the clarity of The test showed your

liver is normal and healthy.Encourage the patient to think of i l lness as a chal-

lenge. Most patients will have faced one or moresevere challenges in their l ives. Invoke their pastsuccesses in coping or mention those of other pa-tients, saying. for example, Im always surprised

at how well patients do. . . Work to improve patients function and participa-

tion in their health care. Help them understand thattheir thoughts, att i tudes. and activit ies affect howthey feel, and stress the importance of learning torelax, identifying new sources of pleasure and selfesteem, and learning coping skills from other pa-tients.Help patients learn how to face and deal with theiri l lness realistically. Patients who focus exclusivelyon positive approaches may delay and inhibit theirown grieving or feel guilty if they cant laugh orlove their cancer away. These patients, and theirfamilies, may need permission to accept and grievetheir losses. Other patients cope best by consis


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GIVING BAD NEWS 19

tently f ight ing the disease and mainta ining a posi -t ive focus, in the face of all odds, to the very end.

THE HEALTH-CARE TEAM

Although the physic ians role i s to del iver the badnews, other health-care team members also play im-

port an t ro les .Nu rs es ca n be pr es en t for th e gi vin g of bad new s,

interpret i t if necessary, help patients verbalize theirfeelings and questions, and provide emotional sup-

port. Nurses are trained to evaluate patients emo-tional and physical responses to treatment. their levelsof comfort and activity, and their progress toward ex-

pe ct ed goa ls . Som e nur ses ar e al so ski l le d at en sur in gthat treatment decisions are congruent with the over-all direction and goals of care.

Social workers are skilled at identifying resources,enhancing coping ski l l s , and working wi th pat ients

fami l ies . Chapla ins can help in ident i fying and meet -ing patients spiritual and emotional needs.

Nutritionists, physical therapists. and clinical phar-macists specializing in palliative care can also make

impor tant cont r ibut ions to the management of ser i -ously ill patients.

Occasionally patients and families will need refer-

ral for counseling or other mental health services.Indications for referral include prolonged or atypical

grief, particularly when it interferes with daily activi-t ies or medical care; concern about a patients suicidepotential if given bad news; difficulty communicating

within the family or with health-care providers: andass is tance in maximizing coping ski l l s . Mental heal threferrals are most successful when the referring physi-cian explains the goals of the referral to the patientand tells the patient what to expect:

DOCTOR: This physician may find ways in which youand I can work together more effectively. Dr. Pierce willtalk to you and then call me to make a care plan.

It is important to ensure follow-up care:

DOCTOR: Id like you to make an appointment to seeme after youve seen Dr. Pierce so we can make some

plans together.

For a physician, checking in with ones own feel-ings i s an invaluable ski l l . D issocia t ing f rom painfulfeel ings protects physic ians psychological equi l ib-rium and allows them to conduct the tasks of medicalcare objectively. Experiencing and expressing feel-ings that arise in the course of professional activit ies,however, are an important component of physicianwell-being. Patients nearly always sense what their

ph ys ic ia ns ar e fe e li ng . Th ey of te n val ue de mo ns tr a-tions of personal caring and express their apprecia-tion: I knew the doctor really cared about Jimmywhen I saw tears in his eyes when he was talking tous. In some cases, physicians may need to identifyand talk about their own grief with a trusted colleague

before-and after-giving the bad news to the patient(see Chapter 8).

SUGGESTED READINGS

Brewin TB: Three ways of giving bad news. Lancet1991;337: 1207.Buckman R: How to Break Bud News: A Guide for e l t hCare Professi onal s. Johns Hopkins University Press.1992.

Butow PN et al: When the diagnosis is cancer: Patient com-munication experiences and preferences. Cancer

1996;77:263Charlton RC: Breaking bad news. Med J Aust 1992;157:615Cresgan ET. How to break bad news-and not devastate the

patient. Mayo Clin Proc 1994;69: 1015.Fallowfield L: Giving sad and bad news. Lancet1993;341:476Girgis A, Sanson-Fisher RW: Breaking bad news:

Consensus guidelines for medical practitioners. J ClinOncol 1995;13:2449.

Krahn GL, urnA. Kime C: Are there good ways to givebad news? Pediatrics 1993;91:578

Maguire P Faulkner A: Communicate with cancer patients:Handling bad news and difficult questions. Br Med J1988;41:33Muller JH, Desmond B: Ethical dilemmas in a cross-culturalcontext: A Chinese example. West J Med 1992;157:323

Ptacek JT. Eberhardt TL: Breaking bad news: A review ofthe literature. JAMA 1996;276:496

Quill TE. Townsend P: Bad news: Delivery, dialogue, dilem-mas. Ann Intern Med 199 1;15 1:463

Tolle SW, Elliot DL, Girard DE. How to manage patientdeath and care for the bereaved. Postgrad Med1985:78:57

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