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Professional Liability


Strategies for breaking bad news to patients

Communication is healing to all involved when you bring your personal strengths to this difficult task. The author offers a set of skills.

September 2008 · Vol. 20, No. 09

The author reports no financial relationships relevant to this article.

Editors’ note: This article appears under the “Focus on professional liability” series banner even though Dr. Bub’s discussion does not directly address matters of being sued. Our, and his, belief is that good communication brings a significant added benefit of lowering a physician’s litigation risk.

  • It was tiring to try and think logically as the guy threw more and more facts at me.—An adolescent with cancer 1

Consider the findings of two surveys of radiology residents and attending mammographers on breaking bad or troubling news to patients:

  • 16% of residents and 4% of mammographers “didn’t feel confident communicating with patients who displayed strong emotional responses”
  • 86% of residents and 81% of staff experienced “some or moderate stress communicating the need for biopsy”
  • The majority of all respondents “hadn’t received feedback about their communication skills or communication training after medical school”
  • 68% to 78% of respondents expressed interest in “improving their communication.” 2

Breaking what you might perceive as “bad” news is never easy; even experienced practitioners may find the task stressful, as the results of these two surveys reveal. Physicians having been trained to do no harm, few find themselves at ease revealing information that has the potential to disappoint or upset, even devastate.

In this article, I offer an approach to breaking bad news in a manner that lessens the trauma to the patient and buffers you from the stress, and distress, of delivering it. The box near the end of this article gathers pearls for giving bad news based on my work and the experiences of others.

We are not unaffected by this task

Most of us find the act of breaking bad news a professional burden that we could just as soon do without. When we perceive an element of personal responsibility, our burden becomes greater: We may experience fear, guilt, or shame—and, for some, that leads to psychological stress disorders and burnout.

How do we cope, being occasional messengers of bad news?

We avoid. An obvious strategy. Consider Dr. D., a radiologist who heads a breast imaging center. He confides that many physicians ask him to inform their patients when he notes an abnormality on their mammogram. Still other physicians, Dr. D. points out, simply have their nurses call patients with troubling results.

Or we run. Another widely used strategy is to break the news and bolt. One cancer survivor lamented: “As soon as I started to cry, he ran off to fetch his nurse. Don’t you know doctors flee from suffering?”

Keeping matters in balance—that is the challenge

How do we maintain our sensitivity, humanity, and connection while, simultaneously, limiting our own vulnerability and pain? Many of us have wrestled with this issue from the earliest days of training:

  • In the hospital’s predawn stillness, she confided fears about surgery to me, the medical student. I tried to reassure her. They operated. Finding extensive metastases, they closed immediately. That evening, aching for her, I cried.
  • “Don’t worry,” another student reassured me. “It gets easier.”
  • I hope not. If it does, I’ll have lost my humanity. 3

There are more questions to challenge us: How do we break bad news in a way that is least traumatic to the recipient? How can we be honest and open yet, when pressed, offer some hope when—objectively—there is little cause for optimism? How do we communicate important information regarding treatment options, prognosis, and so forth, at a time when the patient is least able to absorb it?

Simultaneously, how do we handle our feelings of impotence, failure, and, perhaps, guilt—when every expression, gesture, word, and silence are potentially filled with meaning to those who are receiving the news?

David Lenz, an artist, in a commentary on his award-winning painting, “Sam and the Perfect World,” wrote:

  • My wife Rosemarie had just given birth to our son Sam, and although he appeared perfectly healthy, something, nevertheless, didn’t seem right. There was an awkward silence in the room, no words of congratulation or comments about how cute he was—even though he was cute. Five minutes later the diagnosis was given: Sam has Down syndrome. “Are you going to keep him?” a nurse asked. Later that evening someone else came by to “console” us.
  • “It’s every mother’s worst nightmare,” she said.
  • Welcome to the world, Sam. 4

Many in our profession advocate a disingenuous connection/separation approach to giving bad news—a so-called detached concern. Our professional journals recommend that we examine and control our emotions in the interest of “objectivity” 5 and invest in deep and surface acting (of empathy). 6 I disagree with this advice 7 ; instead, I advocate that we notice, validate, and park our emotions. Later, we take time to integrate our emotions through self-care. Rather than relying on “the art of medicine” to communicate bad news, we should approach this task as a serious professional challenge and incorporate principles of trauma counseling, psychotherapy, and chaplaincy into the practice of medicine. Instead of distancing from our emotions and our patients, we draw closer.

Here is how one physician handles breaking bad news.

CASE

Dr. Bob, we’ll call him, typifies the overworked primary care physician. Yet, when a lab or imaging report that reveals an abnormal result lands on his desk, he, not a nurse, calls the patient. He waits a few days if the test or study was ordered by another physician; in that situation, he often reaches a frightened, confused person who had already been called by the specialist’s nurse.

When that happens, Dr. Bob invites the patient, and a close relative, to schedule an office visit with him. In the interim, he forms a liaison with the specialist so that they can function as a team.

At the office visit, Dr. Bob refuses to prognosticate. Instead, he recommends that they take matters “one step at a time.” His approach is positive and reassuring but not overly optimistic. His message is clear: “You are not alone. I will be a supportive presence throughout your journey.”

Two notable things about Dr. Bob: First, he does not suffer burnout or what some have called “compassion fatigue”; to the contrary, the relationship he forges with his patients and their loved ones, and the gratitude and loyalty he receives from them, sustain and reward him.

Second, Dr. Bob has never been sued.

The key to Dr. Bob’s success is that he does not shy from breaking bad news. Instead, he views the occasion as an opportunity for healing. His approach is to detach from the outcome but not from the patient. He relieves fear and isolation, and offers, as one patient said it, “candor with hope.”

Summon your personal strengths to succeed

But taking this approach requires a shift from the standard biomedical philosophy—a three-pronged cultivation of personal resources. Here is how you can make that shift.

First, cultivate equanimity—that evenness of mind

Consider that destruction is an inherent component of creation. There can’t be light without darkness, birth without death, joy without suffering, perfection without imperfection. The Sufi mystic, Rumi, said it succinctly: “A butterfly needs two wings to fly.”

Recognize that not all news is equally bad. The spectrum runs from merely inconvenient to utterly devastating; how the news is perceived and received is highly subjective. Avoid projecting your personal perspective onto the recipient:

  • I was totally perplexed. I had just broken the news that Mrs. Smith had an incurable colon cancer, and they responded by nodding, then asking me whether I preferred a chocolate cake or an apple pie for their next visit because it was their custom to bring home-baked goodies for the staff.
  • After her death, Mr. Smith faithfully continued this tradition. Then one day he arrived for his regular appointment unshaven, distressed and sans cake. He had lost weight and looked every bit of his 78 years. Something was very wrong.
  • “She’s gone, she’s gone,” he lamented.
  • At last he’s grieving flashed through my mind, so I responded: “Yes, it’s been about 9 months now, hasn’t it?”
  • “No, just two weeks…she said she was my girlfriend…just 29 years old…moved in last month then left taking my money,” he cried.

What seems an obvious tragedy may not be unwelcome:

  • She assumed the mantle of a grieving widow. Only years later did she write that she had been secretly relieved that her husband was killed in an automobile accident. He had been abusive and she was planning to leave him anyway.

Seemingly innocuous news can be most unwelcome:

  • It was my birthday, and we were about to celebrate with a dinner of leg of lamb and roast potatoes. My cell phone rang. It was my internist calling; my LDL cholesterol was mildly elevated and my dexa scan demonstrated slight osteopenia. The tone of his voice was matter-of-fact but I felt awful: I am getting old.

Because bad is so subjective, we cannot presume, without inquiry, what the impact of our words will be on another person.

Realize that long-term well-being doesn’t depend on good vs. bad news:

  • What do Chuck Close and Dan Gottlieb have in common? Each was a healthy young adult when suddenly becoming paraplegic—Chuck from a spinal artery thrombosis, Dan from a serious accident. Each adapted to his condition. Chuck developed a unique style of painting that established his fame as an artist. Dan, a psychotherapist, became an author, teacher, and highly regarded radio interviewer. Each has recently stated that he has never been happier.

Contrast this condition with that of some lottery winners. Many go on to financial and social ruin and come to regret the day that they heard the “good” news.

Remind yourself of hidden opportunities. Bad news triggers a crisis—an unwelcome, unstable situation with obvious danger. Less apparent is the potential for positive personal transformation and gain:

  • “It was the best thing that could have happened to me,” she said, lying with her right foot propped up, ankle heavily bandaged with pins and rods protruding. “Yes, it’s a horribly fractured ankle but I had been rushing, rushing, rushing, and when I fell down the steps, it was as if an angel was forcing me to slow down, be present to my family. I really think this fractured ankle was the best thing that could have happened—it may even have saved my marriage.”

In terms of our own equanimity, news is just news; until the entire scenario is played out, we can’t know with certainty what is bad or good. Recipients of news are entitled to their own reactions even if they seem inappropriate to us. Our role is to support our patients empathetically, without judgment or prejudice.

Second, cultivate yourself as a healer

You may not always be able to cure but you can always facilitate healing. In addition to a treatment plan, remind yourself to create a parallel healing plan, listing the interventions that will help the recipient integrate losses and become as functionally whole as possible.

Your ability to heal depends as much on who you are as what you do:

  • Work through your own trauma stories and you reduce the likelihood that you either attempt to rescue, or flee from engagement with, patients when their problems trigger painful memories for you
  • Accept your imperfections as an inseparable aspect of your humanity
  • Learn to accept life as a journey, with suffering and death being inevitable, and bad news ceases to be so exceptional
  • Deepen your own joy, mindfulness, and faith and you find meaning in your work even when you cannot cure
  • Have realistic expectations of your abilities and try to cultivate a realistic attitude in your patients:
  • In Western culture there is a belief, conscious or not, that medicine can save us from the death that lies in wait for us… In a study conducted in 2006 among Israeli doctors, 68% of the participants reported that patients had unrealistic expectations of them. The study reflects unrealistic expectations of medicine in general. 8
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