Medicolegal Issues

Strategies for breaking bad news to patients

Author and Disclosure Information

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


 

References

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 cancer1

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”

Pages

Next Article: