Case Scenario: You are caring for a previously healthy 52 year old man with a one-month of abdominal pain and weight loss. On exam he had a 2 cm hard left supraclavicular lymph node. A CT scan showed 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 consistent with metastatic stomach cancer. How do you discuss these test results with the patient?
Steps in Delivering Bad News
1.Determine what the patient & family knows; make no assumptions. Examples: What is your understanding of your present condition? What have the doctors told you?
2.Before presenting bad news, consider providing a brief overview of the patient’s course so that every one has a common source of information.
3.Speak slowly, deliberately and clearly. Provide information in small chunks. Check reception frequently.
4.Give fair warning – I am afraid I have some bad news – then pause for a moment.
5.Present bad news in a succinct and direct manner. Be prepared to repeat information and present additional information in response to patient and family needs.
6.Sit quietly. Allow the news to sink in. Wait for the patient to respond.
7.Listen carefully and acknowledge patient’s and family’s emotions, for example by reflecting both the meaning and emotion of their response.
8.Normalize and validate emotional responses: feeling numb, angry, sad, and fearful.
9.Give an early opportunity for questions, comments.
10.Present information at the patient’s or family’s pace; do not overwhelm with detail. The discussion is like pealing an onion. Provide an initial overview. Assess understanding. Answer questions. Provide the next level of detail or repeat more general information depending upon the patient’s and family’s needs.
11.Assess thoughts of self-harm
12.Agree on a specific follow-up plan (I will return later today, write down any questions.). Make sure this plan meets the patient’s needs. Involve other team members in follow-up.
Precepting Points
Residents often feel strong emotions when they have to give bad news to a patient. 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. As a preceptor, you will want to support the resident. Key teaching points:
- Residents may not spontaneously discuss their own emotional reaction with a preceptor, therefore you will want to introduce this topic.
- Physicians often have strong emotional reactions when a patient encounters bad news. This is normal and OK.
- Three methods for coping with these feelings: Identify your feelings (anger, sadness, fear, guilt); Talk with a colleague; Keep a personal journal.
See related Fast Facts: Delivering Bad News – Part 1 (#6); Death Pronouncement (#4); Responding to Patient Emotion (#29); Dealing with Anger (#59); Family Conferences (#222, 223, 224, 225, 227).
Resources
- Buckman R. How to break bad news: A guide for health care professionals. Baltimore, Johns Hopkins University Press: 1992.
- Faulkner A. Breaking bad news – a flow diagram. Palliative Medicine. 1994: 8;145-151.
- Iverson, VK. Pocket protocols—Notifying survivors about sudden, unexpected deaths. Tuscon, Arizona, Galen Press: 1999.
- Ptacek, JT, Eberhardt, TL. Breaking bad news: A review of the literature. JAMA. 1996; 276(6): 496-502.
- Quill TE. Bad news: delivery, dialogue and dilemmas. Arch Intern Med. 1991; 151:463-468.
- Girgis A, Sanson-Fischer RW. Breaking bad news: consensus guidelines for medical practitioners. J Clin Onc. 1995; 13:2449-2456.
- 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: 2nd Edition published September 2005. 3rd Edition May 2015. Current version re-copy-edited May 2015.
Fast Facts and Concepts are edited by Sean Marks MD (Medical College of Wisconsin) and associate editor Drew A Rosielle MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact’s content. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts.
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