Delivering 'Bad' vs 'Serious' News to Patients

Neil Chesanow

Disclosures

January 27, 2016

In This Article

"Bad" vs "Serious" News

Because few clinicians are trained in delivering bad news, some inadvertently undermine patient trust and satisfaction by communicating news bluntly in a detached, mechanistic manner; creating false hopes through use of excessive optimism; withholding adverse information, such as a poor prognosis, from the patient; and giving the family—but not the patient—information, Dr Back says.

Positioning or framing the news is important. It can put the patient in a state of mind to take constructive action, even if the diagnosis is catastrophic and the prognosis is grim. For this reason, after years of telling his patients, and teaching his students to tell their patients, "Mr Smith, I'm afraid I have some bad news to tell you," Dr Back now substitutes the word "serious" for the word "bad."

"When I tell the patient, 'I have some serious news for you that we have to talk about,' I'm saying that this is something we can work on together," Dr Back explains. "That is far different from saying, 'I have bad news,' and implying that you're just going to have to suck it up. That puts people into a negative space."

Framing the news as serious rather than bad is constructive for the doctor as well. "I think of this as serious news because, as a doctor, I talk to people about serious things," Dr Back elaborates. "The frame of seriousness opens up what my role should be: I should help people figure out what's really worth doing."

Preparing to Deliver Bad News

At a growing number of medical schools, students are taught a protocol for delivering serious news to patients in a step-by-step way that's both constructive and empathic. It's expressed by the mnemonic SPIKES, where S stands for setup, P for perception, I for invitation, K for knowledge, E for empathy, and S for summarize and strategize.

Dr Back teaches the SPIKES protocol to his students at the University of Washington and recommends it to practicing physicians as well through a website he and several colleagues have established at VitalTalk.org, where techniques for doctor/patient communication, including delivering serious news, are demonstrated via role playing in free didactic videos.[3]

Setup refers to thinking through the conversation you will have with the patient in your office beforehand and being clear in your own mind about your goals for the meeting. When scheduling the visit, outpatient physicians should anticipate an emotional reaction from the patient and allocate more time than the usual 15 minutes. Inpatient doctors should think of a private place in which to deliver serious news rather than do it in a public waiting room or hospital corridor.

The American Medical Association's (AMA's) Education for Physicians on End-of-Life Care Participant's Handbook includes a module on communicating bad news that employs the SPIKES protocol. "Before starting to communicate any news, plan what will be discussed," the module advises.[4] "Confirm the medical facts of the case. Ensure that all the needed information is available. If this is an unfamiliar task, rehearse what you will say. Don't delegate the task."

"Every physician has a different comfort level in dealing with the fallout of conveying bad news," notes cardiologist Kevin Campbell, MD, assistant professor of medicine at the University of North Carolina in Chapel Hill, whose latest book, Losing Our Way in Healthcare: The Impact of Reform (World Scientific Publishing), includes a chapter for physicians on delivering bad news.

"Subconsciously, many physicians may not want to deliver bad news because they don't want to get involved in that type of emotional situation, nor do they feel like they have the time when they have 10 minutes scheduled for the visit," Dr Campbell observes.

"But if you're going to say, 'You have a stage-3 tumor in your colon, and the chances of you surviving this treatment are less than 50%,' you can't deal with that in 10 minutes," he maintains. "You need to spend 30 minutes or an hour with that patient because you've got to help them grieve and start the process of: 'This is the plan.' It's going to put you behind for the rest of the day, which will affect how you schedule other patients during that day."

Consider how difficult the discussion will be, Dr Back advises. You might want to discuss this with a member of your staff or a colleague beforehand; have the patient's family member, significant other, or caregiver present when you deliver the news; or have a nurse or social worker present if it's a hospital setting. Turn off your cellphone and, if you're in your office, let your staff know that you aren't to be interrupted. Don't deliver the news standing up or from behind your desk, which makes you seem distant or aloof when the situation calls for being empathic. Sit beside or near the patient. Have a box of tissues close at hand.

"One pitfall is that I might rush through this news because I'm busy or distracted, or I didn't expect to get this lab result or report about the patient, and it throws me off-base," Dr Back adds. "Doctors may get thrown off track, and then they just blurt out the news. They think they're being honest, or they think that, 'Oh my God, I've got to get this off my chest,' and they forget that the way in which they deliver serious news is as important as the news itself."

"How you put the news out can determine whether the patient leaves feeling, 'Oh my gosh, I'm screwed!,' or whether they leave feeling that, 'Wow, this is important. I'm going to need to do something about it.' It's a huge difference. My real goal is not just to make sure the patient understands the information I impart but also to make sure I've engaged them in the problem in a constructive way."

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