Delivering bad news

[michelle]

I have a question for the intelligent folks on this board.

I often have to break bad news to a patient. We are not really "trained" for this in medical school, and most doctors develop their own style after watching several of their preceptors during residency training.

For those that have had bad health news delivered to them, or can imagine having the news broken to them, how do you think you would prefer to hear it? One approach, often favoured, is to close the door, sit down, look the patient in the eye, and slowly go through the sequence of events that led to the diagnosis/inability to treat the deadly or painful condition. Then that is usually followed by "I have some bad news", and then you break the bad news and give the basic outcome which is usually certain death, or sometimes permanent disability/pain. Then the doctor allows for any questions.

The breaking-the-news-slowly technique can go on for 5 minutes before I get to the crux of the matter, and I've often wondered if it might not be better to break such news more quickly. For example: "Good morning Mrs Jones. I am sorry to say that I couldn't get all the cancer out. There is nothing more I can do. I'm sorry this has happened to you." After which I could ask the patient if they had any questions.

Any opinions on what you would prefer or things you would like to hear in such a situation?

 

[Meadbh]

Welcome to the forum, Michelle. Any chance you could introduce yourself on the "Hi, I am..." forum? We would like to get to know you before responding to your inquiry.

 

[Bestwifeever]

I don't think it matters--the person receiving the news moves on immediately to dealing with whatever the news is, not how the news was delivered.

Maybe give some direction about what happens next, who to turn to, whatever.

 

[Helen]

I don't think it matters--the person receiving the news moves on immediately to dealing with whatever the news is, not how the news was delivered.

Well, it does need to be said with compassion. A friend's Mother was told she had cancer in a really rude way. During a time of crisis an insult adds a lot of salt to the injury.

I was told I had a brain aneurysm over the phone while at work. The doctor then said that he couldn't answer any questions I might have since it was outside of his area of expertise. I was OK with that because I had access to the internet, plus I didn't waste a trip to his office.

I think you will get a variety of answers to your question.

 

[eytonxav]

While it will not change the outcome, I would think a mixture of compassion in delivering the bad news, plus any recommendations on how to deal with it would be preferable to a quick succinct message. I have always appreciated Doctors that have spent time to explain things and didn't treat me like just another number and I don't see why it would be any different if the outcome is not a good one.

 

[l2ridehd]

How about "I got some good news, you have plenty of time to get all your final plans in place so that everything is done the way you want it. The bad news is you better start working on it now and get it done quick".

 

[Rich_by_the_Bay]

I generally deliver such information (I've done it a lot) using direct and basic information that I think is essential for the patient to know. Then I offer my empathy and sympathy, sit back and listen and watch. The patient drives further information by asking for it directly ("so show long do I have?") or indirectly ("that doesn't sound good...").

This is a very intricate dance and family is often involved. Patients usually don't need protection from the truth (notwithstanding family opinion to the contrary), they just need good information, a ton of kindness and dignity. There is a tendency to want to say too much at the first meeting, and I usually told my students to err on the side of listening - you can always go back again.

Of course in the real world it is a much messier affair with some combination of sadness, anger, denial, family involvement, etc etc. I don't know the OP's role, but this kind of learning is best acquired using both didactic sources (classes and lectures) as well as intense mentoring with senior faculty or colleagues.

Feel free to PM me if you wish. I am a retired academic internist/hospitalist last sighted at a large tertiary cancer center, with 25 years preceding that doing primary care.

 

[REWahoo]

I have a question for the intelligent folks on this board.

I think what you're saying, although I'm not quite smart enough to be sure, is that you don't want to hear from the rest of us. No wonder...

How about "I got some good news, you have plenty of time to get all your final plans in place so that everything is done the way you want it. The bad news is you better start working on it now and get it done quick".

 

[Bestwifeever]

Well, it does need to be said with compassion. A friend's Mother was told she had cancer in a really rude way. During a time of crisis an insult adds a lot of salt to the injury.

I was told I had a brain aneurysm over the phone while at work. The doctor then said that he couldn't answer any questions I might have since it was outside of his area of expertise. I was OK with that because I had access to the internet, plus I didn't waste a trip to his office.

I think you will get a variety of answers to your question.

I had a little situation a few years ago where a test was done, I had a followup appointment with the doc initiating the test, who said my primary care (who referred me to him) wanted to talk to me, and five hours later my primary doc tells me the news. There was no real reason to wait for the PC doc and the five hours waiting to hear were terrible (and the news was not that bad after all, but of course we imagined the absolute worst given that we had to wait to hear). Just tell me already, I don't care how!

 

[donheff]

Probably differs a lot. I think I would like a straight shot followed by details, next steps etc. After getting a death sentence I think a technical discussion would ease the mental transition. I would expect many others would not like to keep talking at all.

 

[LOL!]

Do any of the docs ask their patients how they want to hear about the results before the tests are given? I ask because I think different people would want to hear different ways.

Personally, I prefer my news to be straight and blunt. I don't need sympathy or empathy from my doctor.

 

[TromboneAl]

I do not like "I've got some bad news" because I always imagine something worse. It's taken me years to train Lena on this.

Lena: I've got some bad news...
My thoughts: Cancer, death, car crash?
Lena: I bought the wrong kind of butter.

 

[tmm99]

I do not like "I've got some bad news" because I always imagine something worse. It's taken me years to train Lena on this.

Lena: I've got some bad news...
My thoughts: Cancer, death, car crash?
Lena: I bought the wrong kind of butter.

 

[REWahoo]

"Train"?

 

[Gumby]

"Train"?

Exactly like training a cat. Totally futile, and painful for all involved.

 

[Rich_by_the_Bay]

Personally... I don't need sympathy or empathy from my doctor.

Yep, it's those damn kind, empathetic, sympathetic ones we gotta weed out.

 

[GregLee]

When I woke up after a colonoscopy, my doctor said something close to this: Unfortunately, I did find a cancer, but it is operable. That was a good report, I thought, getting to the bottom line in just a few words. If the news had been worse, perhaps I would wanted it to be drawn out with background details, but I don't think so. It doesn't seem compassionate to me to take a long time getting to the point.

 

[michelle]

Do any of the docs ask their patients how they want to hear about the results before the tests are given? I ask because I think different people would want to hear different ways.

Personally, I prefer my news to be straight and blunt. I don't need sympathy or empathy from my doctor.

Asking the patient in advance is a really good idea. So often the news is not bad though, so it might seem like a fairly morbid question to ask everyone before I know what is really going on.

I have found that there are a fair number, like you, that don't want all the sympathy dance and sugar coating. I can usually sense it after a minute or two into the discussion, but occasionally not before they become quite angry and demand the news. I suspect that moment becomes etched in their and their family's memories for the rest of their remaining lives. It's worth trying to do right, and I think I might try asking the patient in advance how they like to hear news as you have suggested, but perhaps only in situations where I am suspicious the results might be bad.

Meadbh I will try to get around to posting something in the introductory section when I get a chance....

 

[michelle]

I generally deliver such information (I've done it a lot) using direct and basic information that I think is essential for the patient to know. Then I offer my empathy and sympathy, sit back and listen and watch. The patient drives further information by asking for it directly ("so show long do I have?") or indirectly ("that doesn't sound good...").

This is a very intricate dance and family is often involved. Patients usually don't need protection from the truth (notwithstanding family opinion to the contrary), they just need good information, a ton of kindness and dignity. There is a tendency to want to say too much at the first meeting, and I usually told my students to err on the side of listening - you can always go back again.

Of course in the real world it is a much messier affair with some combination of sadness, anger, denial, family involvement, etc etc. I don't know the OP's role, but this kind of learning is best acquired using both didactic sources (classes and lectures) as well as intense mentoring with senior faculty or colleagues.

Feel free to PM me if you wish. I am a retired academic internist/hospitalist last sighted at a large tertiary cancer center, with 25 years preceding that doing primary care.

Thanks for the advice. While I think I am getting better at this, I do have the tendency to try to say too much....too much detail about the pathology. Perhaps it is human nature to want to keep talking.

 

[samclem]

Probably differs a lot. I think I would like a straight shot followed by details, next steps etc. After getting a death sentence I think a technical discussion would ease the mental transition. I would expect many others would not like to keep talking at all.

+1. I'd like to get to the point rapidly, but not in a rude/brusque way.
Good: "Well, samclem, you know that we ordered the Zvactyop test to determine if your cancer was aggressive. And the news is bad--it is aggressive and it has metastasized." (then discuss how things likely go from here, if the patient is open to it, discuss general courses of action)
Bad: "Looks bad for you--maybe 6 months. Talk it over with the oncologist. Gotta go"

Yes, the news itself is important, but the patient and family will always remember the moment the news was broken, and how it was done. That should be in a matter-of-fact way but with all the compassion that is consistent with the goal of communicating clearly. If a doc can't identify with the patient as a person, then he should probably find one of the many important areas in medicine that don't require interaction with patients.

 

[East Texas]

I think people going in for specific tests already have an idea they might have "whatever". As a lay person, I prefer you look me in the eye and, with compassion, tell me "we ran xxx tests to confirm or eliminate your having xxxx". I have the results of your tests and, unfortunately, they confirmed xxxx". What this means to you is xxxxx. The next step is to xxxxx. What questions do you have for me right now? "

Then I want you to act as if you have all the time in the world to discuss the illness with me. You won't need to spend that much time with me - just reassure me you'll be available for questions and you will make sure I have what I need (medically / emotionally) to help me deal with this crisis.

 

[MichaelB]

The physician needs to find a way to communicate unfortunate news without conveying hopelessness or insecurity.

Straightforward delivery of the facts in lay language. An acknowledgement of the shock and pain. A recommendation of what to do next, how to find the necessary resource, and perhaps a referral. I wouldn’t expect sympathy now, unless we had a longer term relationship or the situation were very bad, but some empathy, confidence in his/her judgment, and a clear sense of next steps to help the patient focus.

 

[antmary]

I think a short and empathetic delivery of the information is helpful. "We received your test results from the lab, and I am sorry to say that...."

Including words such as "Sorry to say" humanizes the physician delivering them, while being able to keep a professional distance.

Then, a conversation may begin...it seems that drawing out the bad news can seem like a form of manipulation. I would want to hear the facts, and then segue into a conversation about treatment options.

 

[Nords]

I have a question for the intelligent folks on this board.
For those that have had bad health news delivered to them, or can imagine having the news broken to them, how do you think you would prefer to hear it? One approach, often favoured, is to close the door, sit down, look the patient in the eye, and slowly go through the sequence of events that led to the diagnosis/inability to treat the deadly or painful condition. Then that is usually followed by "I have some bad news", and then you break the bad news and give the basic outcome which is usually certain death, or sometimes permanent disability/pain. Then the doctor allows for any questions.

The breaking-the-news-slowly technique can go on for 5 minutes before I get to the crux of the matter, and I've often wondered if it might not be better to break such news more quickly. For example: "Good morning Mrs Jones. I am sorry to say that I couldn't get all the cancer out. There is nothing more I can do. I'm sorry this has happened to you." After which I could ask the patient if they had any questions.

Any opinions on what you would prefer or things you would like to hear in such a situation?

Well, it's not like I'm going to tell a doctor "Goddammit, doc, get to the point". Not when I've been awaiting the test results, or after they've just managed to "control" the hemorrhaging.

But I've sat through more than my share of doctor's visits with physicians who dearly love the sound of their own voice.

Having delivered my own share of bad military news over the years, I prefer the doctor's approach of "I have bad news, but we can discuss some options." I'd prefer this even if my options are limited to "morphine or Vicodin".

 

[Gumby]

Well, it's not like I'm going to tell a doctor "Goddammit, doc, get to the point".

I might well say that. The older I get, the less tolerance I have for obfuscation and delay. Just cut to the chase. Then we can talk about options.