Sharing Bad News with Patients
No one ever wants to be the bearer of bad news. When you work in the medical field, bad news has a whole different meaning than most other fields. Bad news means quality of life or even life or death news. So it is important for people in the medical field to know how to deliver strategic news, so that even if they cannot make the situation better, at least they can avoid making the situation worse. I am writing this article because unfortunately, I have shared a lot of bad news this month. I have diagnosed more patients with cancer and placed more patients on hospice this month than I have in the previous eleven months combined. It never gets easy to share bad news, and no one wants experience in this area. This month has reminded me of the importance of sharing bad news in the right way.
For starters, who should deliver the bad news? If you know the patient well, you should be prepared to be the one to talk to the patient. If you do not know the patient at all, perhaps someone else may be better suited to deliver the news. Once, I had a patient who had a cancer relapse. This patient had already established a relationship with the oncologist in previous years during treatment, so I asked the oncologist to talk with her instead of me because I felt it was more appropriate. It is not about passing the burden to someone else, but rather thinking about the best way to approach the subject. If there was not someone better suited to share the news of relapse with my patient, I would have been the one to tell her. In these cases it’s important that you know how to deliver this news.
Two years ago, I met a man with Lou Gehrig’s disease. His wife spoke to me about how her husband was diagnosed. Even years after the diagnosis, she was livid and tearful when speaking about it. According to her, the provider called the patient into his office and told him he had Lou Gehrig’s disease, a degenerative fatal diagnosis. He did not say much more than the diagnosis and then the patient was expected to leave the office. The patient was in shock and had no loved ones around for comfort. He was scared and alone at arguable the worst moment of his life. No one should experience bad news this way. The news itself may be bad but the delivery doesn’t have to be. This wife went on to be an advocate for Lou Gehrig’s disease and the proper etiquette in sharing bad news.
So how do we deliver bad news? Obviously hitting a patient with this bomb and walking away expecting them to cope is not a good idea. The most important thing you can keep in mind when delivering bad news is support. When you know you need to deliver bad news, your patients should be asked if they have family they are close to or other loved ones. You should make every effort to instruct the patient to bring family into the office with them. In the hospital, instruct the patient to call their families to come in so you talk with everyone. If it is okay with your patient, you can even call the families, ask when they will be coming into the hospital and let them know you will speak with them when they arrive. There may be some fear with this build-up, but ultimately, you want the people who will be affected by your news to be together when it is delivered so they can cope together. Imagine if someone were to tell you that you had cancer, you would likely want your loved ones to be there to hold your hand, give you hugs and cry with you. When you are telling the patient the news, set aside time in your day to do so. You can expect a long discussion and a lot of questions. Sit down beside the patient. You should be honest and factual. Avoid giving your patient false hope. Although you need to be honest and straight forward, you do not need to be a robot. You can cry and hug the patient, if they are okay with hugs. Sometimes the news you’re about to share can tear someone completely apart.
Some of the most difficult topics to approach are cancer, HIV other terminal disorders, hospice, death, congenital disorders and degenerative disorders. In my field, hospital medicine, I do not see pregnant women or children, so I cannot shed much light on congenital disorders. I also rarely am the one to diagnose a new degenerative disorder or HIV. However, I see a fair share of newly discovered cancer and other terminal disorders. I also do place patients on hospice. Unfortunately, sometimes my patients in the hospital do die.
Let’s talk about cancer, the big C word. No one wants to hear they or a loved one has cancer because that term is associated with death and suffering. When you giving someone this diagnosis, make sure family or loved ones are present. You should also be prepared to answer a lot of questions. Familiarize yourself with the treatment options and prognosis so the patient can have an idea of what to expect. If this is a very aggressive form of cancer, do not lie and give false hope. If it is a fairly benign form of cancer, be honest about that too. Make sure you help the patient set up appropriate follow up. You need to be prepared because your patient and family will not be. Howver, usually, the diagnosis of cancer is not completely out of the blue because first you will see a suspicision lesion and speak with the patient about that. The patient will have a biopsy and ultimately get their diagnosis. No step along the way to this diagnosis is easy. Patients will often be anxious and terrified as they await results. When you discover cancer extremely late, sometimes you may approach hospice without any biopsy results.
Hospice can be an extremely tricky subject to approach with a patient and family because many people have misconceptions about hospice. People often think hospice is cruel. The reality could not be further from the truth. Hospice is a way to preserve dignity and provide comfort care during the end of life. It allows patients to find peace and perhaps even joy in their last days and months of life. It is important when you are approaching the subject of hospice, you dispel myths. Patients and families have the choice of where they would like to provide hospice care. Hospice care can be done in the home with visiting nurses. When a patient is acutely dying, they may benefit from inpatient hospice where nurses and aides are present 24/7 to assist with comfort care. Sometimes when you are approaching the issue of hospice, the patient is not capable of understanding their diagnosis or prognosis and make decisions for themselves. In these cases, the patient should have a power of attorney, which you must speak to.
Explaining to a patient and family that the patient is dying and will likely no longer benefit from treatment can be very challenging. You should always give patients and family all of their options and explain the most likely outcomes. Explain that you could continue aggressive care, such as feeding tubes, life support, surgery, dialysis etc, but explain the course of the illness and that even with all these aggressive measures, the patient will likely die. The other option is remove all care and let the patient be comfortable. People are more accepting of hospice when a patient is older and has been sick for a long time. Some people are not willing to give up until a certain amount of aggressive treatment has already been attempted. Respect the patient and family’s wishes and be honest.
If you work in a hospital, surgical or emergency medicine setting, you are more likely to see patients pass away unexpectedly. This subject is never easy, no matter how often you deal with it. The first time I ever dealt with an unexpected death was on a holiday. Obviously, the family and our staff were devastated. We did CPR for over an hour with the family watching, screaming and crying. I would say that is probably the worst case scenario, but no scenario is easy to deal with. If the patient is alone, one or more people should be trying to contact family members while the rest of the team is dealing with the rapid response, unless the patient is DNR/DNI, in which case you must respect these wishes and aggressively try to contact the family.
Sharing bad news in the medical field is always difficult for everyone involved. The best thing you can do is follow the golden rule- treat others how you would want to be treated. Remember to ensure your patient is surrounded by loved ones, be empathetic and always be honest. I hope you never find yourself having to give bad news, but if you do, now you know how to approach the issue with sensitivity and respect.
1-13-17 Update: As recommended by an W Jones MPAS, CCPA, PA-C in the comments below, here is a video about the SPIKES approach: