doctor giving bad news to patient
Although compassion and empathy are innate qualities, specific education and training can sharpen and improve these physician attributes. Photo source: iStock

Fumbling the delivery when delivering bad news to a patient about a new cancer diagnosis or another illness with a particularly poor prognosis can lead to lasting negative effects on the patient and their families. This can irreversibly damage the doctor-patient relationship.

There is a great need in our health care community for educated and insightful communication. Physicians have a duty to be honest with their patients while making them feel safe and reassured.

A cancer diagnosis, unsuccessful procedure or an unwanted test result causes fear and confusion in the patients we’ve sworn to protect. The reality is that some physicians are ill-equipped to handle what comes next.

Here are 5 tips on what NOT to do when delivering bad news to patients:

1. Don’t Assume You Have the Training

Delivering a medical diagnosis in clinical terms and explaining how that will impact the rest of a patient’s life are two different methods of communication. While 91% of surgeons believe delivering bad news is an essential skill as a physician, only 40% felt they had received appropriate and effective training to deliver it.

Although compassion and empathy are innate qualities, specific education and training can sharpen and improve these physician attributes. Traditional medical education does not necessarily address these issues formally.

Many studies have found a wide divergence in curricula that teaches physicians effective behaviors and communication strategies. In some trials, a brief intervention was all that was required to improve physician empathy as rated by patients.

      • Teaching compassion in medical school

Many courses on compassion and caring are new to medical schools. In the past, physicians had considered kindness and understanding a given. No professional training was provided on the topic. Admittance into medical school was enough of a test to gauge communication skills.

As a thoracic surgeon who has practiced for more than 14 years, I’ve been fortunate to guide patients through life-changing decisions every day. Yet, there is always something I can learn from every new encounter.

The skills of kind, compassionate yet effective communication isn’t written between the lines of diagnostic textbooks. Luckily, more medical schools are realizing the importance of healthy patient interaction.

      • Delivering bad news

Regardless of what we have been taught as health care providers for communicating with patients, it’s easy for each delivery of bad news to feel like the first time.

Luckily, there are more resources than before to help patients through one of the most difficult days in their lives. From online emotional training to virtual reality, there are many opportunities to broaden your communication skills and provide the best support you can for your patients. Here are some tips:

2. Don’t Forego Building a Relationship

Sometimes you might be tasked with delivering bad news to a patient or a family member you’ve only met minutes prior. However, there is no substitute for building a foundation of trust.

This is true even if provided with only a short amount of time to do so. Simply electing to ignore that requirement could cause lasting harm. Figure out what your patient is looking for in their provider and show them you can be that for them every step of the way.

      • Trust

Bonding with a stranger is something we have to do with every new patient. How do you ask someone you’ve never met to trust you with their life? First impressions matter. Take these things into consideration:

            • how you dress
            • how you speak
            • what your body language is saying
            • how you move about the room 
            • how your staff interacts with you

Trust is hard-fought and well earned. It is the foundation of a healthy doctor-patient relationship.

      • Learn about your patient

You’ll want to know the patient as much as you can beforehand:

          • Review their chart, medical record, and scans BEFORE you enter the room.
          • Memorize all of the pertinent facts.
          • Do NOT type on your computer or ruffle through papers in front of them.
      • Make the patient feel special

Even if you have a very busy clinic, make every patient feel that they are your only patient that day. They are your No. 1 priority.

Schedule a longer appointment to allow ample time for discussion. By providing a generous appointment window, you give yourself time to learn your patient’s preferred method of communication and a good deal of their personality.

      • Engage with the family

Introduce yourself to the patient and everyone in the room. Take a moment to learn their names and relationships.

Initially, avoid using humor or touch to establish a relationship with patients or family members with whom you’re not yet familiar. You may do so as the encounter progresses based on cues you observe from the patient and their family.

      • Family support

Provide a safe space for the patient to tell you which family members they would like in the room. Ask the patient how they would prefer that others be involved in their care and any discussions about their health.

Making sure a patient has familial support (whether in person or via telephone in certain circumstances) when receiving bad news is important, The patient should have the space they need to process the news alongside loved ones who will provide the most support.

However, avoid undue stress from too many reactions, hysteria and negative emotions in the room. Be a pillar of strength as everyone in the room will look to you for leadership and guidance. Be in control while allowing enough latitude for the patient and family to express their emotions.

      • Family dynamics and cultural considerations

If the patient is someone who has been in your care for a long time, consider their personality and family dynamics, and identify coping mechanisms they may have used in the past. Being sensitive to a patient’s cultural and religious background or specific fears can go a long way in earning their trust.

Related Content:
Trust is the Essence of the Doctor-Patient Relationship
Why Medical Translation and Medical Interpretation Services are Key in Quality Healthcare

3. Don’t Muddle the Message

Many providers are used to delivering mundane clinical information in a matter-of-fact way. You may find it acceptable in many visits to list off laboratory results and CT scan terminology only to end with “your lungs look good.” This usually elicits a sigh of relief from the patient. However, the delivery of bad news must be framed differently and not allow room for misinterpretation. 

      • Deliver the message clearly and directly 

          • Use every day conversational language you know the patient will understand
          • Tailor your vocabulary and terminology to your patient’s social context and education level.
          • When using medical terminology, pause frequently and provide an unrushed explanation before moving on.
          • Drawings or images of CT scans can help them understand as “images are worth a thousand words.” Remember that patients often forget the words you said but they will remember an image you showed them.

The patient is about to face a million difficult decisions and a million more worries and fears about their personal life. At the moment you are delivering the news, most patients do not want to know the science or medical vocabulary to describe their illness.

      • Identify how much a patient wants to know.

Each patient must know the truth and how it will affect their future but gauge the level of detail the patient is willing to discuss. Some patients prefer that their physician discuss all of the scientific details.

They want to know the precise statistics about their chances of cure. They want to learn about possible complications and side effects of treatments. And, they want to know what science says about the rate of survival.

Others prefer no details but simply to hear that their physician will take care of them as if they were his/her own family member.

      • Give the patient time to react  

Some physicians become nervous when delivering bad news. This leads them to continue speaking after the initial pronouncement. It is a way to avoid a long period of silence which makes them uncomfortable.

It’s likely your patient is not absorbing much after that first shock. So instead of talking, be silent, wait for a reaction and provide frequent pauses. Keep eye contact, slowly approach the patient, observe them and react to their verbal and non-verbal cues.

      • Don’t ask “do you have any questions?”

Don’t ask “do you have any questions” and expect an immediate response. The patient may not have enough time to form their thoughts. Instead, ask “what questions do you have?” That will prompt your patient to search for their biggest concern and phrase it as a question.

Giving the patient time to breathe and letting their first concerns rise will help you target the most important topics your patient wants to discuss.

Related Content: 4 Ways You Can Improve Patient Engagement

4. Don’t sympathize, empathize

Sympathy is easily confused with empathy but often is less useful and potentially harmful. While sympathy expresses feelings of pity or sorrow, empathy portrays the ability to understand and relate to someone else.

Remarks such as “I know how you must feel,” or “I had a family member with the same issue” only makes the discussion about yourself. Providing empathy requires understanding what the patient is processing and reacting accordingly.

      • Effective tactics for empathetic communication include the following: 

          • Sitting versus standing during patient interaction in order to be at the same eye level
          • Detecting patients’ nonverbal displays of emotion
          • Recognizing cues from the patient and responding to opportunities for physical contact (hand on the shoulder, knee or an embrace)
          • Nonverbal communication such as eye contact and body language
          • Verbal reinforcement of acknowledgment and support
      • Reassure the patient that they are in good hands

Anticipate how the patient will want to process the news and what it will take for them to feel safer, more reassured and in good hands.  It’s fine to say “I’m sorry” but follow with an observation of what they might be feeling. For example, “This must come as a shock but let’s talk through how we are going to treat this.”

      • Be self-aware in your responses

Ask yourself if it is something you would want to hear in their situation. By offering hope with realistic interventions can begin to shift the conversation toward treatment. If a cure is not realistic, be upfront about that fact but offer encouragement about the treatment options and supportive care.

5. Don’t be afraid

The first time you deliver bad news to a patient and don’t get the reaction you were expecting is eye-opening. In fact, every encounter is an opportunity for improvement and fine-tuning.  

Compassionate physicians may be afraid of showing too much emotion during the visit. Instead, they become overly clinical and direct when a family expects a certain level of compassion.

Conversely, a physician who overcompensates by becoming too emotional can lose the trust of the patient or family, seeming weak, inexperienced or not in control. This will diminish their sense of hope and sense of being in good hands.  

      • Your patients will expect a certain level of confidence and strength

They will lean on you for support. Rather than focusing on how the patient will react, have confidence in yourself to identify what they will need when they do react. Do not undervalue your experience but take note of where you can improve.

The bottom line when it comes to delivering bad news

Health care communication is a complex and evolving field. Every doctor-patient relationship is different, and it takes a trained eye and an open heart to successfully navigate each one.

Related content: Listen to Your Patients: They Are Telling You the Diagnosis

Implement methods of empathy and nonverbal communication in your practice. Be a keen observer and pick up cues from your patient and family members. Become familiar with different personalities and identify how they cope with various problems.

It’s never easy to completely upend someone’s life with a piece of bad news. It is  especially difficult when you are dealing with someone you may have met only moments prior.

It takes guidance and experience to make that person feel like they are in good hands. With the right amount of confidence, empathy, and hope, you may find remarkable gratification in providing unwavering support when your patient needs you the most.

Jacques Fontaine, M.D.
Dr. Jacques Fontaine, M.D. has been a thoracic surgeon for over 14 years.  He is a Senior Member of the Thoracic Oncology Department at the H. Lee Moffitt Cancer Center in Tampa, FL as well as a Professor at the University of South Florida.

As the Director of the Mesothelioma Research and Treatment Center at Moffitt Cancer Center, he and his team of oncologists, radiologists, pathologists, and nurses work to personalize mesothelioma treatments to each patient with specialized care.  Dr. Fontaine began his mesothelioma training at Brigham & Women’s Hospital in Boston where he established his skills under renowned thoracic surgeon Dr. David Sugarbaker.

Through the years, he has developed an international reputation as an expert in robotic surgery for lung and esophageal cancer. He is the Director of Moffitt’s Thoracic Surgery Robotic Fellowship Program and has proctored dozens of thoracic surgeons across the country.

Dr. Fontaine is a frequent contributor to Asbestos.com. He also has numerous publications in scientific journals, including reports in the European Journal of Cardiothoracic Surgery, Journal of Thoracic Disease and Annals of Thoracic Surgery. To learn more about Dr. Fontaine, you can find him at Florida Chest Surgery.

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