According to Ronald E. Waldridge, a family physician in Kentucky who recently lectured at the National Congress of Family Practice Residents on how to impart bad news to patients, creating an appropriate atmosphere in which to deliver the information is critical. "Good news is spontaneous: 'Mr. Brown, you have a bouncing baby boy.' Bad news requires planning," says Waldridge. Before meeting with a patient or the patient's family, Waldridge recommends that the physicians find an appropriate, private setting (complete with a box of tissues) for a face-to-face meeting. Sort out the medical events that led to the diagnosis, and translate medical jargon into layman's terms.
Balance candor with hope
No one knows better than a patient how it feels to receive bad news. That's why one group of researchers turned to patients with chronic and terminal illnesses and their family members to identify communication areas of central importance. Overwhelmingly, participants identified a strong desire for physicians to deliver news with a mixture of candor and hope.
One family reported that their physician managed to do just that: "He was honest with us, but he never did anything to our hope ... he didn't belittle it and he didn't build it up." In the face of a terminal illness, it may take creativity to deliver hope — but it can be done. "If cure is not an option, then hope may be oriented toward maximizing quality of life and making the patient comfortable," explains Marjorie D. Wenrich, dean of the School of Medicine at the University of Washington, and author of the study, which was later published in the Archives of Internal Medicine.
Elicit patients' preferences
In most cases, a patient-physician relationship does not end with the delivery of bad news. In some instances, it is only the beginning. Just as thriving patients have goals, so do those who are dying. According to Howard Brody, MD, principal author of an article on compassionate clinical management published in the New England Journal of Medicine, the goals of a dying patient and his or her family — not available technology — should dictate that patient's plan of care.
Physicians should find out what's important to the patient and family members, such as whether they wish to maintain the patient's ability to communicate, whether interventions judged to be particularly burdensome should be avoided, and how best to maximize the patient's and family's comfort.
Make yourself available
In any medical situation that involves delivering bad news to a patient, a physician's tendency to avoid that patient is extremely common. Says one physician respondent in Wenrich's study, "I didn't really involve myself with the patient. And I still, to this day, regret my level of involvement with that patient."
Avoidance, of course, is the exact opposite of what many patients want and need at such a time. Instead, they long for physicians who are willing, and who take the time, to listen. Just how well a physician listens is sometimes hard to gauge; one way is to note how frequently physicians ask their patients open-ended questions, as opposed to those that require just a "yes" or "no" response. Says another study participant, the daughter of a terminally ill patient, "What I found helpful was the doctor really made herself available to the family as well as to my mother and said, 'Please, please, ask questions.'"
No one likes to deliver bad news to a patient. But when it's done with foresight and followed up with an equal amount of care and compassion, it can actually help ease a patient's anguish — and the physician's.
Elizabeth Heubeck can be reached at editor@physicianspractice.com.
This article originally appeared in the January/February 2002 issue of Physicians Practice.
