How should physicians give bad news to patients?

When I see patients in the office, I try to guess their occupations from their demeanor and mannerisms. Salesmen are the easiest to ID. In general, they are gregarious males with manly handshakes. They laugh loudly and like to tell jokes. Teachers are more reserved and often give their narrative in a logical and chronological order, as would be expected. Another clue that the patient is an educator is that their appointments are usually in late afternoons. I have a solid record picking out the engineers and scientists. (For physician readers, I estimate that with regard to engineers, my sensitivity and specificity are 60% and 90% respectively.)

Engineers can be tough patients for gastroenterologists to treat. They operate in a computational universe, where numbers add up and problems have concrete solutions. Doctors, particularly gastroenterologists, function in an entirely different milieu. Our world is nebulous. Engineers see mathematical truths, while GI physicians see fog. When they see us with chronic nausea and abdominal pain, they are frustrated when we cannot provide them with a satisfying diagnosis.

I recall an engineer I saw some time ago. He was neatly attired and related his ominous symptoms in an intellectual manner, as if he were giving traffic directions. He was having trouble swallowing his food and was steadily losing weight, a presentation that generates the highest level of physician concern.

I scheduled him for a scope examination of the esophagus, and found the expected cancer. Afterward, he was seated with his wife as they awaited the news of my findings.

These minutes when we physicians know the bad news, and the patient doesn’t, are ponderous. We wish we could hold on to the secret and spare patients from the knowledge that will change their lives so brutally and irrevocably. Subconsciously, we stall. During those minutes, hours or sometimes days, physicians are in a different dimension, a medical ‘twilight zone’. Once we relate the news, however, we are hurled back to earth. Once the patient knows, then we are enveloped by an aura of cold reality.

How should physicians give bad news to our patients? Should we be blunt? Do we front load the heavy news or lead to it after several introductory sentences? Should we use euphemisms like “growth,” when cancer is the right word? Should we spin the information with hope and optimism, even if the medical facts contradict this assessment? Do we tend to sugarcoat for our own benefit as well as to soothe the patient? Should serious medical news ever be delivered on the telephone? How do we respond if the patient asks, “am I going to die?”

There is no standard strategy of how to do this right. In addition, patients are distinct human beings and must be approached individually. See First, a blog that emphasizes the importance of communication between physicians and patients, writes that false hope for patients may be the wrong prescription. Medrants, an academic physician and thoughful blogger, speaks for all physicians when he writes, breaking bad news may be the most difficult and important part of our profession.

I have spent 4 years in medical school, 3 years in an internal medicine residency followed by 2 years of fellowship training in gastroenterology. During those 9 years, I don’t recall a single lecture on how to deliver bad news to patients. Yet, I remember memorizing biochemical equations, the names of minute nerves and muscles, the function of microscopic components of cells, hundreds of medications and the natural history of arcane diseases that I have never seen in my career. The astute medical interns and residents I admired were those who could spew off the dozen or so medical explanations for an elevated calcium blood level. I wonder if medical training, at least in my day, had proper priorities for training physicians. Doc Gurley, a physician and folksy and irreverent blogger, recalls a single lecture she heard as a medical student on how to deliver bad news to patients. It impacts her practice to this day, two decades later.

Delivering bad news is a very difficult and unavoidable responsibility of a physician. Do I do it well? I think so, but I’m not really sure. I gave the news to my patient and his wife after I had made arrangements for him to see the necessary consultants in the coming days. I think that patients’ stress in these situations is eased when there is a plan that we physicians put in place. He listened without demonstrating emotion, and thanked me for my time. He then left with his worried wife. The news was still in his analytical left brain, where he stores his facts, figures and formulae. What happens when it crosses the Rubicon over to the other side?

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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  • drseno

    Good questions! As a young widow, a nurse researcher and educator, and an end-of-life communication expert, I share a few pieces of information that may help.

    First, patients DO know. Most people, with any awareness at all, know within themselves, what’s going on. There are tens of thousands of situations that support that claim, and none that deny it.

    How does that help you? I puts you in a different role. You’re not alone with the information to begin with, and your approach to patient and family with news is more collaborative than you think it is.

    You’re not taking hope away at this point, but helping people shift to a different hope — hope that the time they have remaining will be what they want it to be. There’s a lot of things clinicians do that interferes with patients and families even coming to know about *that* hope, let alone to carry it out.

    We always have hope, but it’s not hope that we should live forever. Who wants that anyway? Our true hope is that our living is happy. People can be and are happy and fulfilled when dying or anticipating grief.

    Start this way: Before patient and family leave with this news, be sure to ask them what’s most important to them right now…that will give you a clue as to what they need next. You can’t guess what their answer will be. Of course you have to be authentic when asking that question.

    There are indeed standard mnemonics for this conversation that can ‘help’ They’re all over the literature, and have been for years. They are helpful if you also have a sense of how to be-with, be present with people when they embark on this journey. Any mnemonic is useless if you don’t know how to be present. That takes intention and practice.

    You may find the complimentary 4-lesson MINI COURSE “Mastering the Listening Self: Personal Growth Through End-of-Life Encounters” helpful. You can find it on my website, Esse Institute.

    Best wishes as you find ways to make this easier for clinicians, families and their dying members.

    P.S. There’s an awesome dissertation on the website too “Being-with Dying: Tacit wisdom embedded in the experiences of nurses who attend to dying.” People love reading that work. My favorite physician loved it. We had many coversations over it :)

  • http://twitter.com/bostongal1641 bostonmeg

    I think it is always important for Doctors to remember to give this
    information (or any health information) directly to the patient – not to
    the spouse or parents because that’s easier. I cannot tell you how
    many times I have Doctors talk around me like I wasn’t in the room.
    It’s rude, adds to the stress and is counterproductive.

  • http://twitter.com/SueWintz Sue Wintz

    As a board certified chaplain affiliated with HealthCare Chaplaincy in New York, I have been with many physicians when they delivered bad news as well as teaching inservices to both physicians and medical students on how to communicate with patients and families. It sounds to me like you’re on the right track by noticing the differences in your patients and how they give/process information. As a chaplain, when I do a spiritual assessment I’m identifying what a patient’s beliefs and values are, communication style, cultural issues, and their resources for emotional, religious, spiritual and/or cultural strength and coping. I’m also on the outlook for what those things are for families and where the differences may lie. That information, as part of the interdisciplinary team approach, is then shared with the physician and often we discuss the best approach before he/she has the conversation with the family. This, of course, leads me to the belief that having a professional chaplain in not only healthcare organizations but physician practices contributes to best patient care and increased communication in one of the most cost-efficient ways. A chaplain is also a great resource for offering an educational opportunity for physicians.

    All physicians in an office will have a health history completed by their patients. I’d recommend that a screening also be done for spiritual, cultural, religious, and communication needs. The questions need not be long or complicated, but they can give insight, raise red flags, and identify places where there needs to be more conversation before THE conversation – and/or a consult to a board certified chaplain working with the practice to see the patient and family as part of the whole person care.

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