Do you get sweaty palms whenever you have to deliver bad news to a patient?

Consider yourself lucky. It’s when you feel no anxiety while telling a patient her biopsy is positive, or that her cancer isn’t responding to treatment that you should worry about yourself. But while it’s natural to be uneasy, being incompetent at communicating difficult, even heartbreaking, news isn’t really excusable. It could be the difference between comforting a seriously ill patient or just making matters worse.

You only get one shot at giving a patient bad news. You have to know how to do it right.

“If you do it well, you’ve probably helped the patient and family through an extremely difficult transition,” says Jerry Old, a Kansas City-area family physician and hospice director, says. “If you do it poorly there will be bitter memories for a long time and it could make the grieving process worse.”

Old, who lectures at the University of Kansas School of Medicine in addition to directing Hospice Care of Kansas, says the rapid aging of the U.S. population adds urgency for physicians to learn how to discuss death and dying with patients.

“Eighty-five and up is the fastest-growing segment of the population, but life is finite and the mortality rate is 100 percent so we are going to be dealing with a lot more end-of-life issues very soon,” he says.

Old points out that improving one’s skills in communicating bad news can have a practical side effect: patient and physician satisfaction tend to go up when physicians move smoothly from the curative to the palliative approach.

“If you can make that transition, you won’t blame yourself or feel like a failure when the patient does die,” Old says. “You’ll feel like you helped, and that’s the satisfaction of practicing medicine.”

Do the seven steps

Although physicians can find a growing array of articles, continuing medical education seminars, manuals, workshops, and even fellowships in palliative care, many still don’t know how to support dying patients properly.

David I. Wollner, a New York City physician trained in geriatrics and oncology, says it doesn’t take extensive training to communicate well and show empathy.

“Put the same kind of energy into that training as you’d put into learning something like a cardiac catheterization. You’ll get to where you can do it well every time,” says Wollner, who is director of palliative care for the Metropolitan Jewish Health System in New York City.

Wollner recommends a seven-step communication process outlined nearly 10 years ago by the Educating Physicians in End of Life Care (EPEC) project. The project — an effort by the American Medical Association and the Robert Wood Johnson Foundation — suggests that physicians approach patients to whom they must give bad news by:

• Preparing. Choose a quiet, comfortable location where there will be no interruptions, turn off pagers and phones, and decide — asking the patient, if possible — who else should be in on the discussion. Adds Wollner, “Make sure you truly know all of the medical details of the patient’s case beforehand.”
  
  
• Assessing. Find out what the patient already knows and wants to know. “Some people want every laboratory test, every fact you can give them, while others, often the elderly from other cultures, may say, ‘You’re the doctor, you decide’ or ‘Talk to my son or daughter,’” Wollner says.
  
  
• Warning. Old calls this “firing a warning shot.” It is simply saying, “I have some bad news.”
  
  
• Describing. Present the facts of the case in a succinct but caring way and in terms that patients with no medical background will easily understand. Don’t talk for too long, suggests Thomas McCormick, a medical ethicist at the University of Washington School of Medicine in Seattle. “After you say a word like ‘cancer’ they aren’t going to hear much of what comes after that,” he says.
  
  
• Pausing. Sit quietly until the patient responds to the news. How long should you wait? It may feel like an eternity to you but imagine what it feels like for the patient, says Old. If there is no response he suggests asking, “Can you tell me what you are thinking about?”
  
  
• Validating. In addition to assessing the patient’s emotional response and answering questions, try to empathize with the feelings expressed. When answering questions, give the information in small chunks, Old says.
  
  
• Planning. Always end the discussion by presenting a follow-up plan. This can be as simple as setting up another discussion later in the day. “You want to ensure continuity of care for the patient, give a clear picture of the next steps, and make sure somebody is around to answer questions,” Wollner says.