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.
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.
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.
Table 3–1. Techniques for giving bad news. |Favorite Table|Download (.pdf)
Table 3–1. Techniques for giving bad news.
Forecast possibility of bad news
Clarify who should attend the bad news visit
Clarify who should give the bad news
Give bad news in person
Give bad news in private
Sit down and make eye contact
Identify what the patient already knows
Give the news clearly and unambiguously
Identify important feelings and concerns
Remain with the patient and listen
Use empathic statements
Invite further dialogue
Use simple, clear words and concepts
Summarize and check patient's understanding
Use handouts and other resources
Make a plan for the immediate future
Ask about immediate needs
Schedule a follow-up appointment
Case Study: "This Could Be Cancer"
Preparing for the Discussion
When cancer or other serious illness is a strong diagnostic possibility, consider discussing it with the patient early in the workup:
Doctor: That shadow on your x-ray worries me. It ...