Case Scenario:  You are caring for a previously healthy 52 year old man with new abdominal pain.  After conservative treatments fail, a diagnostic abdominal CT scan is done showing a focal mass with ulceration in the body of the stomach and numerous densities in the liver compatible with liver metastases.  The radiologist feels that the findings are absolutely typical of metastatic stomach cancer.  How do you prepare to discuss these test results with the patient?

Preparing to Deliver Bad News 

1.Create an appropriate physical setting: a quiet, comfortable room, turn off beeper, check personal appearance, have participants – including yourself – sitting down.

2.Determine who should be present.  Ask the patient who they want to participate and clarify their relationships to the patient. Decide if you want others present (e.g. nurse, consultant, chaplain, social worker) and obtain patient/family permission.

3.Make sure you know basic information about the patient’s disease: prognosis, treatment options, next steps.

4.Special circumstances: If the patient lacks decision-making capacity (e.g. developmentally delayed, demented, delirious, etc.), make sure the legal decision-maker is present. See Fast Fact # 226 Helping Surrogates Make Decisions.

5.Special circumstances: If the patient or family does not speak English, obtain a skilled medical interpreter.  Use phone translation services if necessary.  See Fast Fact #154

6.Special circumstances: If the patient or family is of anther cultural background, see Fast Fact # 216 Asking About Cultural Beliefs in Palliative Care.

Precepting self-reflection    Residents will invariably have strong emotions when they have to give bad news.  This emotional response can be heightened by various factors—a young patient, an unexpected diagnosis, a patient with whom the physician has a long-standing relationship, etc.  Preceptors need to support the resident.  Key teaching points:

1. Residents may not spontaneously discuss their own emotional reaction with a preceptor, therefore preceptors need to introduce this topic. “This is a really hard case, how are you doing?”
2. Physicians often have strong emotional reactions when a patient encounters bad news.  Normalize the experience for the resident. “It’s normal to have strong feelings”.
3. Three methods for coping with these feelings are: Identify your feelings (anger, sadness, fear, guilt); Talk with a colleague; Keep a personal journal.

  4.  Role play the discussion with the resident before you go into the room; ask them to reflect on how it “feels”…what is hard…what         is easy.  Encourage continued self-reflection.

See related Fast Facts: Delivering Bad News Part 2 (#11); Death Pronouncement (#4); Moderating a Family Conference (#16, #222, 223, 224, 225, 227); Responding to Patient Emotion (#29); Dealing with Anger (#59).

References

1. Buckman R.  How to break bad news: A guide for health care professionals.  Baltimore, MD: Johns Hopkins University Press; 1992.
2. Faulkner A. Breaking bad news – a flow diagram. Palliative Medicine. 1994: 8;145-151.
3. Iverson, VK.  Pocket protocols—Notifying Survivors About Sudden, Unexpected Deaths. Tuscon, AZ: Galen Press; 1999.
4. Ptacek, JT, Eberhardt, TL. Breaking bad news: A review of the literature.  JAMA. 1996; 276(6): 496-502.
5. Quill TE. Bad news: delivery, dialogue and dilemmas. Arch Intern Med. 1991; 151:463-468.
6. Girgis A, Sanson-Fischer RW. Breaking bad news: consensus guidelines for medical practitioners. J Clin Onc. 1995; 13:2449-2456.
7. Von Gunten CF, Ferris FD and Emanuel LL. Ensuring competency in end-of-life care: Communication and Relational Skills. JAMA. 2000; 284:3051-3057.

Version History:  This Fast Fact was originally edited by David E Weissman MD.  2nd Edition published July 2005; 3rd Edition May 2015. Current version re-copy-edited May 2015.