Telling a patient that he or she is gravely ill alters the life of that patient forever. Mike Power offers some advice on how to go about breaking bad news with the necessary preparation, empathy and directness
What unites Italia ’90, the death of Princess Diana and the 9/11 bombings? They are all what psychologists call ‘flashbulb memories’, in that everyone remembers exactly where they were and what they were doing when they heard the breaking news of these epoch-making events. It is true to say that a flashbulb memory usually has a highly emotional aspect to it, which further aids recall.
A patient’s memory of learning about the seriousness of a health condition is similarly vividly recalled. “This couldn’t be happening to me.” “Things will never be the same again.” “It must be a mistake.” These are typical of the comments made by patients. It is important that doctors appreciate the feelings that patients and their families have on hearing such life-altering medical news.
Breaking bad news to patients is more that delivering cold medical facts. It is a complex process that involves carefully managing the consequences. The issue of patient rights has lately come to the fore, with many hospitals now operating an open disclosure policy. However, clinicians need to bear in mind that many patients and families may not want to know everything and that this right also needs to be respected and considered when doctors are delivering grave news.
Knowing others’ minds
Using the spoken word correctly is a sophisticated and multi-purposed human skill that can be used to both conceal and elucidate. Doctor-patient conversations, whereby sombre news is being delivered, are especially delicate and sensitive. Content, tone and body language tally up to the virtuoso performance of conversation – the pinnacle of human mental accomplishment.
We can look to the great dramatists when considering the limitations of language. This can help us to understand that language can often fall short when struggling to make sense of life or to express our inner-selves.
In Samuel Beckett’s play Waiting for Godot, Vladimir and Estragon take refuge in a language that creates a parallel reality – a reality sanitised from the unsatisfactory ragged fag-ends of ordinary life. Of his plays, Beckett himself said: “Each word is like an unnecessary stain on silence and nothingness.”
Great literature emphasises the important role language plays in mediating our relationship with the external world and in abstracting meaning from the seemingly random detritus of our everyday experience. Tom Murphy’s The Gigli Concert (1983) explores in a wonderfully insightful way how language is used in psychotherapeutic conversations about aspects of mental illness and healing with a client.
Patients and doctors have many conversations together, but few resonate such emotion as those relating to life-and-death issues, such as telling a patient they have an inoperable cancer or informing a parent that their little one’s grasp on life is tenuous.
The effective practice of medicine requires a high degree of interpersonal skills. Personality, family background, experience and the exigency of the situation can influence how a doctor is perceived by patients: approachable; distant; self-important; unperturbed.
Aside from that, when dealing with patients, colleagues or non-medics, the ability to deliver clear, confident and compassionate messages is essential to good doctoring. A good communication style is paramount when operating in units such as oncology, HIV or palliative care.
One interesting US study on this particular topic showed female medical students (N=138) three videos of a physician informing a woman that she had breast cancer. The communication styles used were disease-centred, emotion-centred and patient-centred. The patient-centred style was unequivocally seen as the favoured approach by participants in this study.
Margaret is a 30-year-old registrar doing a shift rotation in a HIV clinic. Sara is a 32-year-old woman with advanced HIV who dropped out of college after she found out that she had contracted HIV from her husband, who has haemophilia.
In talking to Sara, it turns out they share a number of things in common – they are both from the same part of Cork originally, they both have young children and they both like to travel. Later on, when Margaret suggests that she will need some blood tests, Sara gets irate and says: “What would you know about this? Is there something seriously wrong?”
How should Margaret deal effectively with this situation?
While the doctor is often the target of a patient’s anger, experienced clinicians recognise this as not personal. A mixture of guilt, anger, fear and irrational shame are often expressed by patients on hearing bad news.
Doctor/patient identifications, while helpful in many cases, can also complicate the treatment of life-threatening conditions. Even at the best of times, life for us all is an uncertain venture. Many illnesses are adventitious, cropping up without warning and striking at apparent random. If serious, these illnesses can radically alter both our daily lifestyles and our hard-won sense of contentment with life.
At some level, we all appreciate the ever-changing nature of all aspects of life and indeed also of ourselves. We can see ourselves becoming older, more vulnerable or more tired than in our youth, but most of us still place our whole confidence in our bodies to combat infections, recover from injury, resist strains and stress and generally successfully carry out the daily business that is life.
We have a great emotional investment in our bodies and its capabilities. And when this cornerstone of our lives is seriously threatened by injury or illness, who can blame us if we react irrationally, become angry, depressed or numb out life altogether?
Being told one has an inoperable cancer that requires dialysis or that an immediate amputation is needed are medical messages that initiate a process (and it is a process) of developing a whole new set of attitudes and life expectations. More often than not, this involves taking stock and reappraising long-cherished future hopes and dreams.
A common thread linking many of the emotional reactions in patients is a deep sense of hurt and disappointment at their bodies ‘letting them down’. Deep depression, withdrawal, fury, total confusion and many other emotions are very common reactions to bad news of this kind. This is even more evident in patients who are at the same time managing chronic pain.
Many seriously ill patients view pain as the harbinger of something more ominous and fearful: the prospect of imminent death. It is this reason that patients often react to bad news by firstly inquiring about the limitations their illness and treatment may have on their daily lifestyle – “Will I still be able to play golf?” “Will I need to take a lot of medication?” “Will I be able to eat normally?”
A patient may make a comment such as: “The doctor talked to me for 15 minutes, but I only remember hearing the word ‘cancer’.” The patient is vividly expressing the emotional shock that comes from hearing the news that turns their whole world upside down. It would appear that the patient does not hear the entire message, but hears it in a manner and context that will assist and support their recovery in the best way possible.
Hearing that you are gravely ill is so life-changing that it shakes the very foundations of a patient’s life. Each patient reacts differently. And just as there is no one formula for delivering this news, there is no one way of predicting how a patient will react.
One helpful tool to use when trying to understand a patient’s emotional response to hearing bad medical news is to liken it to that of bereavement: a devastating emotional loss that requires grieving.
Elisabeth Kubler-Ross’s five stages of grief are: denial, anger, bargaining, depression and acceptance. These stages are not necessarily sequential and patients can dip in and out of all five depending on the progress of their illness. Clinicians can use these five stages as a rough guide in ascertaining their patient’s emotional health.
With regard to the skills of breaking bad news, an important part of a doctor’s training is learning how to communicate well with all sorts of patients, under all sorts of circumstances. Discovering an illness can be viewed as yet another transition in one’s life and has the potential to transform or destroy a patient’s well-being.
Unfortunately, there is no one recommended template for communicating bad news to patients and each practitioner must find an approach and style that best suits both themselves and the given situation. Remember, real medical life is rarely like ER, Casualty or Gray’s Anatomy!
l Listen to experienced doctors or watch videos of expert communicators.
l Picture things from the patient’s point of view.
l Recall what helped you when one of your family members became ill.
Every day, medicine places doctors in situations that are far from ideal. In anticipation of assisting doctors in breaking bad news, the following recommendations should be borne in mind:
l Prepare in advance
It is important to prepare a mental agenda for delivering the communication. Arrange for a family member or other support to be present.
l Reinforce the doctor-patient relationship
It is the strength of the doctor–patient relationship that will determine the success of the meeting. Trust in the doctor is vital to the patient. Remember to respect all individual patient’s customs and backgrounds.
l Set the scene
Choose a quiet, private venue and a suitable time. Consider the emotional state of the patient.
l Body language
Sit at a close, comfortable distance from your patient. Be aware of the unconscious signals you may give. Make eye-contact. Allow for silence if you feel it is helpful.
l Probe to uncover what the patient already knows
Sensitively explore what information the patient already may have about their condition. Try to ascertain if there is anything else they would like to know. Use open-ended questions. Address any fears the patient may have.
l Delivering the message
It helps to give information in bite-size pieces, ensuring that the patient understands as you proceed. Avoid jargon and use clear, concise language. Use commonplace words rather than medical terminology.
Gently reassure and validate the patient’s emotions should they cry, express anger or remain silent. Acknowledge these feelings with empathy. Be sure not to out-rule hope and optimism for the patient.
l Liaise with the family
Family support for the patient is crucial at this time. The family is the unacknowledged healing room for every patient. Be direct, non-partial, honest and sensitive to the dynamics of each family.
l Bookending the session
Before finishing the meeting, be sure to summarise all main points. Clarify any questions and provide explanatory literature if needed. Give a contact phone number and bridge on to the next session by arranging a future appointment.
Breaking bad news is one of the most challenging tasks a doctor can undertake, especially if it triggers events from their personal lives. The skills of those working in oncology and palliative care, especially, have a lot to offer in this regard. Process your own feelings and perhaps discuss with a colleague.
A very useful little booklet called How Do I Break Bad News? is available to download from University Hospital Galway’s Q-Pulse system and provides many useful suggestions on this topic.
References on request.