Breaking bad news to patients is one of the most difficult responsibilities in the practice of medicine. Although virtually all physicians in clinical practice encounter situations entailing bad news, medical school offers little formal training in how to discuss bad news with patients and their families. This article presents an overview of issues pertaining to breaking bad news and practical recommendations for clinicians wishing to improve their clinical skills in this area. Show
What Is Bad News?One source1 defines bad news as “any news that drastically and negatively alters the patient's view of her or his future.” Professional bicyclist Lance Armstrong's recollection of being diagnosed with metastatic testicular cancer exemplifies the impact of bad news on one's self-image: “I left my house on October 2, 1996, as one person and came home another.”2 Bad news is stereotypically associated with a terminal diagnosis, but family physicians encounter many situations that involve imparting bad news; for example, a pregnant woman's ultrasound verifies a fetal demise, a middle-aged woman's magnetic resonance imaging scan confirms the clinical suspicion of multiple sclerosis, or an adolescent's polydipsia and weight loss prove to be the onset of diabetes. How a patient responds to bad news can be influenced by the patient's psychosocial context. It might simply be a diagnosis that comes at an inopportune time, such as unstable angina requiring angioplasty during the week of a daughter's wedding, or it may be a diagnosis that is incompatible with one's employment, such as a coarse tremor developing in a cardiovascular surgeon. When the physician cares for multiple members of a family, the lines between the patient's needs and the family's needs may become blurred. Most family physicians have faced a conference room full of family members awaiting news about the patient, or have been pulled aside for a hallway discussion with the request to withhold the conversation from the patient or other family members. Why Is Breaking Bad News So Difficult?There are many reasons why physicians have difficulty breaking bad news. A common concern is how the news will affect the patient, and this is often used to justify withholding bad news. Hippocrates advised “concealing most things from the patient while you are attending to him. Give necessary orders with cheerfulness and serenity…revealing nothing of the patient's future or present condition. For many patients…have taken a turn for the worse…by forecast of what is to come.”3 In 1847, the American Medical Association's first code of medical ethics stated, “The life of a sick person can be shortened not only by the acts, but also by the words or the manner of a physician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have a tendency to discourage the patient and to depress his spirits.” In the past few decades, traditional paternalistic models of patient care have given way to an emphasis on patient autonomy and empowerment. A review of studies on patient preferences regarding disclosure of a terminal diagnosis found that 50 to 90 percent of patients desired full disclosure.4 Because a sizable minority of patients still may not want full disclosure, the physician needs to ascertain how the patient would like to have bad news addressed. Qualitative studies about the information needs of cancer patients identify several consistent themes, but which theme is most important to any given patient is highly variable and few patient characteristics accurately predict which theme will be most important.5 Therefore, the physician faces the challenge of individualizing the manner of breaking bad news and the content delivered, according to the patient's desires or needs. Physicians also have their own issues about breaking bad news. It is an unpleasant task. Physicians do not wish to take hope away from the patient. They may be fearful of the patient's or family's reaction to the news, or uncertain how to deal with an intense emotional response. Bad news often must be delivered in settings that are not conducive to such intimate conversations. The hectic pace of clinical practice may force a physician to deliver bad news with little forewarning or when other responsibilities are competing for the physician's attention. Historically, the emphasis on the biomedical model in medical training places more value on technical proficiency than on communication skills. Therefore, physicians may feel unprepared for the intensity of breaking bad news, or they may unjustifiably feel that they have failed the patient. The cumulative effect of these factors is physician uncertainty and discomfort, and a resultant tendency to disengage from situations in which they are called on to break bad news.6 Rabow and McPhee keenly describe the end result, “Clinicians focus often on relieving patients' bodily pain, less often on their emotional distress, and seldom on their suffering.”7 Several professional groups have published consensus guidelines on how to discuss bad news; however, few of those guidelines are evidence-based.8 The clinical efficacy of many standard recommendations has not been empirically demonstrated.9,10 Less than 25 percent of publications on breaking bad news are based on studies reporting original data, and those studies commonly have methodologic limitations. Learning general communication skills can enable physicians to break bad news in a manner that is less uncomfortable for them and more satisfying for patients and their families.11 Numerous investigators have demonstrated that focused educational interventions improve student and resident skills in delivering bad news.12–14 Following traumatic deaths, surviving family members judged the most important features of delivering bad news to be the attitude of the person who gave the news, the clarity of the message, privacy, and the newsgiver's ability to answer questions.15 As Franks observes, “It is not an isolated skill but a particular form of communication.”16 How Should Bad News Be Delivered?How can bad news be most compassionately and effectively delivered? Rabow and McPhee7 developed a practical and comprehensive model, synthesized from multiple sources, that uses the simple mnemonic ABCDE (Table 17). The following recommendations are patterned after Rabow and McPhee's ABCDE mnemonic, with modification and additional material from other sources.16–21 Although specific situations may preclude carrying out many of these suggestions, the recommendations are intended to serve as a general guide and should not be viewed as overly prescriptive.
A–ADVANCE PREPARATION
B–BUILD A THERAPEUTIC ENVIRONMENT/RELATIONSHIP
C–COMMUNICATE WELL
D–DEAL WITH PATIENT AND FAMILY REACTIONS
E–ENCOURAGE AND VALIDATE EMOTIONS
Final CommentDespite the challenges involved in delivering bad news, physicians can find tremendous gratification in providing a therapeutic presence during a patient's time of greatest need. Further research is needed to provide empirical support for consensus-based guidelines. However, a growing body of evidence demonstrates that physicians' attitude and communication skills play a crucial role in how well patients cope with bad news and that patients and physicians will benefit if physicians are better trained for this difficult task. The limits of medicine assure that patients cannot always be cured. These are precisely the times that professionalism most acutely calls the physician to provide hope and healing for the patient. Who has the need to know a patient's diagnosis?A patient has the right to information from his or her doctor in order to make informed decisions about his or her care. This means that patients will be given information about their diagnosis, prognosis, and different treatment choices. This information will be given in terms that the patient can understand.
What is the most important thing a nurse can do to enhance communication with a dying patient?Results The following 6 areas were of central importance in communicating with dying patients: talking with patients in an honest and straightforward way, being willing to talk about dying, giving bad news in a sensitive way, listening to patients, encouraging questions from patients, and being sensitive to when ...
Why is communication important in end of life care?Good communication of a dying person's prognosis improves their end of life care and the bereavement experience of those important to them. It can help to ensure that the dying person's expressed wishes are considered and to avoid misunderstandings and unnecessary distress.
How do palliative patients communicate?Find out if they need support to communicate, and include people who know them well. Avoid jargon and unclear language – for example say "dying" instead of "passing away". Find out how they express discomfort or pain. Allow enough time for conversations – be patient and ready to repeat yourself if needed.
|