A guide to giving bad news to patients

The massive magnets of the MRI radiate fields through her brain, scanning veins, arteries and every millimeter of cortex.  Grey and white matter, containing all she is and all she ever will be, identified, cataloged, mapped.  Two centimeters under the front of her skull, just to the left of center, there is an abnormality; a one centimeter mass surrounded by swelling.  The lung cancer has spread, metastasized.  Really bad news.

A patient, whom I have known for many years and consider a friend, asked me recently, “How do you get ready to give bad news?”

She meant this question two-fold.  First, how do I organize the information I am about to reveal and second, how do I steel my emotions for the difficult conversation ahead?   It is an important question and the answer is key to successful relationships between doctors and their patients.

First, it is critical when a doctor has bad news, not to delay in telling the patient.  As I instruct my patients, “if you have had a scan and I have not called you, it is not that I do not have the guts to call, it is that I have not seen the scan.”

Patients worry and worry and worry, and every second of delay makes the news to come worse and wears at the relationship between doctor and patient. Take a deep breath, get it done.

When I first went into practice, my senior partner gave me a fantastic piece of advice.  He said, “Whenever you are going to take, be ready to give.”

What he meant was that when a doctor gives bad news, he is taking away choice, the image of health, and perhaps life itself.  To learn something is significantly wrong with your body is to lose certain possibilities for the future. Bad news given by the doctor can take away hope.

Thus, key to giving bad news is to prepare and be ready to answer the question, “Doc, what do I do now?” It is a mistake to simply walk up to a patient and say, “sorry but the cancer has come back, I’ll get back to you.”

Rather, the doctor must consider what comes next.  This next step may be complex and potentially curative, such as “we need to get a PET scan, a biopsy and to have you see Dr. Smith, who is a surgeon.”  Or the plan may be more supportive, such as, ”Well, when a cancer comes back like this is not curable, but this is how we are going to control your symptoms.”  Perhaps the plan is just a family meeting.  The doctor needs to have considered the next step before he walks in the exam room or picks up the phone.

Bad news should be given in a place of privacy and as another set of ears is invaluable, whenever possible there should be at least one supporter with the patient. I detest giving bad news on the phone, but when it cannot be avoided, I try to set it up that phone conversation beforehand.  Thus, if I am ordering a test whose result I am forced to give on the phone, I say, “now when I call you it is likely to be one of two results, and this is what that will mean.”  Still, scheduling an immediate office visit after the test is performed, is a better approach.

The next steps in giving bad news are patience, time and silence.  Once the bad news is said, most patients shut down.  They lock on the bad news and nothing else the doctor says at that moment is heard.  So, no rush, take your time.  The Inuit people of Alaska routinely sprinkle long periods of silence into casual conversation.  It is a good time to practice that technique.  The doctor needs to resist rushing ahead to explain the plan he has prepared. Sitting together, crying or hugging if appropriate, or just allowing the patient to focus, is necessary.  Many patients need the bad news repeated, which is usually obvious in their response and questions.  Human beings have tremendous powers to cope with adversity, but we are not unfeeling supercomputers: we need time.

As the patient and doctor move forward with the conversation, there are two key elements for the doctor.  Listening and teaching.  The physician needs to listen carefully to what the patient understands and their needs.  If the doctor goes off on a wild tangent, such as “we are going to start quadruple-drug-massive-intensive-ablative-horrendous chemotherapy tomorrow,” and misses the one-year-old birthday party next week, the conversation will be a disaster.

Often a physician can help the patient and family with not only education and information, but also suggesting that a second opinion at this critical moment in a patient’s medical course is never a bad idea.  As I tell patients, “the worst thing that can happen with a second opinion, is that we all learn something.” No matter what, reeducating the patient about the disease process and on choice is vital and such teaching is at the core of the physician’s profession.

This takes us back the vital question asked by my friend: how does a doctor prepare emotionally to give bad news?  I think the answer is that the physician prepares by getting ready to do his job well.  If he does a good job delivering the bad news, than he has helped the patient and family move forward in a difficult time of their lives.  Done well, this is satisfying and important work.  While at times it can be sad and even tragic to work with patients who are experiencing overwhelming health events, if the doctor can guide them through such times, then some element of suffering can be avoided.  The healing of suffering, giving the chance to cope and preserving hope, gives every doctor peace and solace.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • Suzi Q 38

    At least you tell your patients that: “if you have had a scan and I have not called you, it is not that I do not have the guts to call, it is that I have not seen the scan.”

    Some doctors simply forget to call. Also, their nurse does not know, or have any idea of why you need to talk with the doctor. They wonder why you are sooo annoying and call once a day. I would not only ask them to have their doctor call me, but remind them to do so.
    When the nurse kept ignoring my requests, I finally showed up at the office and requested a visit with the nurse and doctor. When the nurse asked why, I told her that I had called 3 times and no one had returned my call. Since the doctor was at another clinic that day, I was out of luck.

    She asked me in front of a room full of patients why I needed to see the doctor. I told her: “Because I have taken about 6 tests in the last 2 weeks, I have called 3 times without a return call, and I want to know if I have MS or not.”
    I then said: “What do I have to do??? Get the head of the department, to find out the answer for me? The Chief medical officer? The nursing supervisor?”

    “Did the nurse even tell the doctor that I have called?”

    I was just curious.
    The nurse got me in my own private room, fast.
    She did not want me to display my frustration in front of the other patients.

    The doctor finally called me, and I got my answer.
    I just knew that I had to get out of that hospital if this is the kind of attention that I get when I need help.

    I switched hospitals, and I am now much happier.
    i wanted a second opinion, anyway.

    • PollyPocket

      It is difficult for doctors, especially those with multiple clinics, to keep track of everything, and things do slip through the cracks.

      That is why they employ nurses. Clinic nurses need to triage clinical phone calls and questions. I have worked in clinics where this was understood and the patients were well served. I have also worked in clinics where the nursing staff saw patients as a nuisance and didn’t return calls like they should have.

      Many very dedicated phycisians have apathetic office staff, which is very unfortunate.

      • Suzi Q 38

        Thanks for your explanation.

        • meyati

          I needed to change oncologists. I let the administrative staff know that I would no longer see the sexist ignorant cruel pig. He wouldn’t even answer basic questions or run blood work for the proposed surgery. I had to take my tattooed biker grandson to scare him into answering questions. That when I added sexist to his resume.
          They just figured that I was taking my anger of having cancer out on them and the doctor-it happens.
          I spent weeks calling, sending Emails, going up. I finally got the name of the clinic administrator by calling the clinic headquarters 2,000 miles away. I was also using the word-lawsuit.
          The clinic administrator agreed right away that I should have a new oncologist, and her staff would call me in a few days with the name and an appointment.

          I waited. Finally I marched up and told them that Cindy said that I was getting a new doctor, was that true? They made phone calls -YES-

          I stood there and they asked me if I needed anything else. I told them that it would be nice, if I knew the name of my new doctor- They told me. OK-I stood there waiting again-they stopped and looked at me. I said that it would be nice if I had an appointment with the new doctor, as I was finishing radiation the following week.

          Yes the staff is apathetic. Sometimes you have to kick start them. Some staffs are on the ball. Even a good staff can have a bad day-and things get lost.

          I had a medical problem. I called the receptionist that I needed to contact the doctor and nurse. I was told to do it electronically-which has a 48 hour turn around. I told her that I knew that she wasn’t the only one to answer the phone, and I’d keep calling until I got somebody else, and I’d tell them about her. She saw it my way. My problem was so serious that the nurse told me to come in immediately. I went in and the nurse was waiting for me. This clinic has about 20 doctors. I told everyone about that receptionist anyway–

      • Judgeforyourself37

        Poorly trained, uncaring, or incompetent staff in any physician’s office can destroy that doctor’s practice. It is imperative, too, that the physician, him or herself is not only knowledgeable and competent, but compassionate and can view her/his patients as whole people.

  • SBornfeld

    Great post–thanks.
    It raises the issue of not only how to communicate, but whether empathy is something that you’re born and raised with, or if it can be learned.
    I don’t doubt that some doctors are beyond help–either because they’re unfeeling bastards or because their own personal difficulties dealing with issues of life and death get in the way.
    But I think most of us CAN learn over time to really listen and empathize. It helps that, as we get older, we gain the experience not only through our patients, but our friends, families, loved ones, and ourselves–as patients on the receiving end.
    This is SUCH important stuff–but I’d bet there aren’t too many questions about managing a grieving patient and family on the National Boards.