A Difficult Chore
Breaking bad news is one of the most difficult responsibilities in healthcare. Virtually all physicians and nurses will need to do this task, yet professional schools and training programs offer little, if any, training in this area. In many ways, this issue of CareMatters was born from failure. When I think back over my fourteen years in private practice doing internal medicine/pulmonary and my last eighteen years being a full-time hospice physician, I can remember many instances when I had not communicated bad news as well as it should have been done. This CareMatters was written because AseraCare Hospice wants to help you to develop this crucial skill.
“No, I didn’t tell him. I just couldn’t. You do it.” The oncologist hung up the phone. My mind condensed the facts. Dan was a 61-year-old man whose visit to the dentist ended with an ambulance ride to a cancer center because he would not stop bleeding. A bone marrow biopsy was followed by the grim shaking of heads by interns, leaving Dan dazed and frightened. Two days later he was discharged to our hospice to ostensibly die in his daughter’s home. The oncologist told me (but not Dan) that Dan probably had only two weeks to live and therapy was futile. So, I was to enter the home of his devoted daughter, two obliviously happy grandsons, a loving wife of forty years, and tell them that Dan would be lucky to see fourteen more sunrises. As I drove to Dan’s house, I wondered, “how could I give such ugly news in a beautiful way?”
A Powerful Tool
No one likes to deliver bad news. And if done poorly, it may rob hope and set off a chain of events that adversely affects the patients and families for years. If done well, with a modicum of compassion and forethought, it is an incredibly powerful tool for good — fostering in patients a positive attitude, strengthening the physician-patient and nurse-patient relationships, enhancing the patient’s faith, and affirming that the patient is not alone.
Bad news is best delivered by you as the medical person closest to the patient. Delegating this to others or doing it over the phone is unacceptable. Create a comfortable private place, have tissues available, and have phone calls held. Since you will need to be relaxed and not rushed, schedule the discussion when you will have adequate time. Preparation should also include asking if there is anyone else the patient would like in the room? I usually encourage patients to bring a family member along. And, of course, have a future game plan ready. Dan wanted his whole family present. So, we set an agreeable time and I drove to their house.
The Visit: Explore and Ask
I have found it wise to begin by asking patients what they feel is medically wrong. A question like, “How do you understand what has happened so far medically?” can give you a good starting point. Surprisingly, Dan and his family only knew that he had a blood disorder. “How much do you want to know?” should be the next question. Multiple studies tell us that over 95% of patients want to know everything. This helps later if a family member asks you to withhold information or is dismayed that you told the patient “all that bad news.” Dan wanted to know everything and everyone in his family heard and understood that wish.
The Visit: Say It Right
Speak in a compassionate tone and avoid medical jargon and technical language. It is better to oversimplify the situation than to muddle it up with confusing data. Give patients plenty of time to react, respond, and ask – allowing pauses and silence so the message can sink in.
Never ever ever say, “There is nothing more I can do for you.” It is a phrase that prompts hopelessness, smacks of emotional and intellectual abandonment, and is downright false. There is always something more you can do for patients if you see them as more than just a disease. Learn alternative phrases like “There is nothing more I can do to halt your cancer, but there is much I can do for you to control your pain and to help you live each day to the fullest extent that you can.”
Nobody in Dan’s family asked me how long he had to live so I brought it up. Let’s be honest: it is the elephant in the room that nobody wants to talk about but everyone is thinking about. Deliver the answer with complete honesty, but tempered with humility, compassion, and gentleness. Honesty – because your patients deserve and expect this virtue in their healthcare professional. Too many healthcare professionals are so non-committal as to be useless and even misleading. Humility – because recent studies show that even doctors can’t predict the timing of a patient’s death as well as they think. Use phrases like “To the best of my knowledge you probably have…months instead of years.” or “…weeks instead of months.” By doing this, it enables patients to get their lives in order and do the meaningful things that they want to accomplish before they die. You would be surprised how many patients never accomplish crucial end-of-life tasks because their doctors and healthcare professionals falsely assumed the patient knew they were imminent. I told Dan, “You probably have weeks to live rather than months.”
Before the Meeting Ends …
Ask if there are any questions. Clearly state that you will remain available and will go through this with them. At this point, if patients have told me that prayer has been an important source of strength in coping with their illness, I will often ask if they would like me to pray with them. This seems to form a special bond and emphasizes care of the whole person. Studies have
shown that about one-half of all patients would like their physicians to pray with them and over two-thirds would like their physicians to address spiritual issues with them. Dan and his family were visibly moved after the prayer. Finally, schedule a follow-up visit in one week.
The Follow-Up Visit
The follow-up meeting should begin with the question, “How did you understand what we talked about last week?” Remember, some patients will remember nothing after they hear the word “cancer” or “hospice.” Correct any misconceptions. During the previous week, Dan, with the help of the hospice counselor and chaplain addressed financial and spiritual issues. I prepared Dan and his family for what to expect medically in the weeks ahead. Dan and his family were very grateful for the support of the hospice team.
Becoming a Real Doctor or Nurse
I was recently giving a Grand Rounds lecture in New York City about this topic. After my talk, an infectious disease specialist at one of the major medical centers told me about his experience dealing with patients with AIDS during the early years of the epidemic. He said, “We had nothing medically to offer these young patients. It was very tragic and sad. However, it was also the time that I became a ‘real doctor’. Because there was nothing to offer from a medical standpoint, I learned to give of myself through caring and compassionate words and actions.”
You will experience tremendous personal satisfaction from telling bad news in a good way and the positive ramifications can last for decades and generations in the survivors. Dan lingered longer than expected – dying four weeks after being admitted to hospice. Cards, with kind words from family, arrived at our hospice for weeks after the funeral.
Introducing hospice to a patient is part of giving hope when giving the bad news. I advise healthcare workers to introduce hospice as a part of what we simply do when “the time comes.” It should not be a “big deal” or an anxiety-provoking time for staff or patients. People should hear the following message “We always provide the best care to our patients and when certain needs arise, we naturally call in experts. For example, if you needed a specialty physician, we would ask him or her to see you. So, it is a part of our routine procedure to call hospice for those patients who we know will benefit. We have seen their expertise and care help countless patients and the families during this difficult time. We always strive to treat our patients as we would want to be treated.”
The communication skills of healthcare professionals play a crucial role in how patients and families cope and handle their illnesses. The very nature of humanity and medicine is that all of our patients will eventually die and most will need to be given bad news. This is precisely the time when “treating a patient” is superseded with caring, providing hope, and giving compassion – the hallmarks of your AseraCare Hospice.