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A debilitating or terminal illness, a catastrophic injury, an unexpected death—these are situations both patients and physicians face, and they are all situations in which the physician must break the news to patients, partners, and family members. How physicians deliver bad news can affect patient outcomes. For example, how parents are told that their child has a developmental disability affects their emotional state, attitudes, and coping. How patients are given a new diagnosis of cancer affects their satisfaction and subsequent symptoms of anxiety and depression. Despite strong emotional experiences when bad news is received, patients and families are able to distinguish between effective and ineffective communication skills, and up to a third report problems with how they received bad news.

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Giving bad news is hard. Most physicians struggle to find the proper balance between honest disclosure and providing encouragement, hope, and support. Physicians giving bad news may experience feelings of sadness, anger, guilt, or failure. Most find it stressful and wish they had more training or guidelines. Patients' and relatives' views on how bad news should be delivered include the need for privacy; for a clear, concise, and unambiguous message; for a caring and concerned manner; for attention to the patient's emotional state; and for the opportunity to ask questions. These views are congruent with expert opinion and the published guidelines adapted for this chapter. The guidelines have face validity but the evidence supporting their adoption into practice, and their impact on patient care, remains preliminary.

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A systematic approach to giving bad news (Table 3–1) can make the process more predictable and less emotionally draining for the physician. The process of giving bad news can be divided into six categories: preparing for the discussion, maximizing the setting, delivering the news, offering emotional support, providing information, and closing the interview.

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Table 3–1. Techniques for giving bad news.
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Case Study: "This Could Be Cancer"

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Preparing for the Discussion

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When cancer or other serious illness is a strong diagnostic possibility, consider discussing it with the patient early in the workup:

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

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