Learning How to Break Bad News to Patients

CLEVELAND—Communicating bad news is an essential part of end-of-life care as well as an important skill in all areas of medicine. Although many physicians feel unprepared to deliver bad news, it is a skill that can be learned and improved, said Donna S. Zhukovsky, MD, director of the Cancer Pain Clinic in the Palliative Medicine Program, Cleveland Clinic Foundation.

Dr. Zhukovsky spoke at a conference devoted to the clinical management of terminally ill patients. The conference was based on the Education of Physicians in End-of-Life Care (EPEC) program, developed by the American Medical Association in conjunction with the Robert Wood Johnson Foundation. Conference participants were divided into small groups for a discussion of communicating bad news and the presentation of a video produced by the EPEC program.

“Breaking bad news begins before the patient arrives,” Dr. Zhukovsky said at one such group discussion. The physician should plan what he or she is going to say and prepare to talk with the patient in private. There should be adequate seating for the patient, the physician, and other family members.”

Although preparation is important, communication doesn’t have to be very time consuming, she said. Physicians who work with an interdisciplinary health care team may find it helpful to have a social worker or nurse present. Once the physician confirms the medical facts of the situation and answers questions, perhaps someone else on the health care team can address other concerns of the patient.

If a translator is needed, find one who understands medical terms and is prepared to translate bad news, Dr. Zhu-kovsky said. Avoid using family members as translators, she added, since an experienced translator will give a more neutral presentation.

Begin by assessing what the patient already knows about the illness. “Start from where they are, not where you are,” Dr. Zhukovsky said. Determine how much the patient wants to know by asking. The physician might say, “Would you like me to tell you the full details of your condition?” or “Do you want me to go over the test results now and explain exactly what I think is wrong?”

Try to be sensitive to cultural differences, Dr. Zhukovsky said. Such cultural differences may inform the way patients and family members respond to medical information. Americans, for instance, may accept the diagnosis but struggle with the uncertainty of the prognosis. Patients from other cultures may find it difficult to hear the diagnosis. In some cultures, cancer is believed to be a consequence of having done something wrong.

In many situations, the family will ask the physician to avoid telling the patient the diagnosis. The family may believe that sharing the diagnosis will take away the patient’s hope. In other cases, family members who have had a difficult relationship with the patient may feel guilty and unable to accept the patient’s likely death. In both situations, the request not to tell is an attempt to protect themselves and the patient from the emotions that accompany a life-threatening illness, Dr. Zhukovsky said.

When faced with a family that says, “Don’t tell,” the physician should ask the family to express their concerns about telling the patient. “Ask family members what it is they’re afraid of,” Dr. Zhukovsky suggested. It may be appropriate for the physician and family together to ask the patient how much he or she wants to know.

A diagnosis of life-threatening illness need not take away hope. “Diagnosis often opens up opportunities rather than closing them,” Dr. Zhukovsky said. Patients facing cancer may use their time to re-examine their lives, to resolve conflicts, complete projects important to them, go on trips, or create a videotape for children to remember them by.

The Horvitz Center for Palliative Medicine at the Cleveland Clinic uses family conferences for its patients as a means of sharing medical information and addressing the patient’s psychosocial needs, she said. The advantage of this is that everyone gets the information at the same time. Family members who live far away can be included with a conference call.

When the patient is ready to hear the diagnosis, give the diagnosis without euphemisms, Dr. Zhukovsky said. “You want to be blunt without being cruel,” she said, “but euphemisms can really get you into trouble.” She described meeting a patient who knew he had had chemotherapy for his tumor, but didn’t know he had cancer. She said she uses the word “cancer” initially during her diagnosis but then will soften her message by using the word “tumor.”

Nonverbal Communication

Present the information in small chunks and respect the ability of the patient to absorb the news, she said. Pause frequently and check for understanding. Be prepared for a broad range of reactions. Nonverbal communication and silence can be very helpful. “Listen quietly and attentively to the patient’s reaction,” Dr. Zhukovsky said. “You learn more by not saying anything. With silence, people will begin talking.”

The phrase “I’m sorry” should be adjusted to make it clear that the physician is expressing empathy rather than apology or pity. “I’m sorry to have to give you bad news” is better than simply saying “I’m sorry,” she said.

If the patient asks for a prognosis, the physician should first assess his or her reasons for asking and determine how specific the prognosis needs to be. It is notoriously difficult to predict how close a patient is to death, Dr. Zhukovsky said. She acknowledged that even after caring for numerous patients who died, she is not good at predicting. The EPEC program suggests responding with a range of time, such as “hours to days,” “days to weeks,” “weeks to months,” or “months to years.”

Physicians can prepare families who are praying for a miracle for unexpected surprises, both good and bad, by presenting medical care within the context of “hoping for the best and planning for the worst,” Dr. Zhukovsky suggested.

Finally, establish a follow-up plan. Explain how the physician can be reached to answer additional questions. Before the patient leaves, make sure he or she is not too distraught to get home safely. If the patient is alone, for example, Dr. Zhukovsky suggested asking, “Should we pick up the phone and have someone come get you?”

The short video viewed by the group showed a scene in which a physician confirms a diagnosis of adenocarcinoma in a patient who has had a colonoscopy for a mass in the descending colon. The doctor introduces the bad news by saying: “I know you wanted it straight.” Other phrases used by the doctor include: “Tell me what you’re afraid of,” and “Is there anyone else I can talk to?” The physician also offers emotional support by offering to “be there” for the patient and by saying, “We’re going to take this one step at a time.”