Family matters

Physicians may sometimes feel that they spend as much or more time talking to and counseling family members than they do the seriously ill patient.

“It wasn’t an obvious point to many physicians, even five years ago, but the family is part of your targeted care,” says Fisch. “The responsibilities for informing them may not be the same as the patient’s but including the family in the process of caring for the patient in the most appropriate way is a key point.”

Families can be harder to deal with, Old says. But taking a team approach that includes nurse practitioners, social workers, chaplains, and other professionals may help ease tensions, he says. Family interference that leads to serious patient noncompliance is talked about far more often than it actually occurs, Wollner says.

“We do ourselves a disservice by imagining that families are going to be the cause of noncompliance,” he says. “I’ve never seen a multidisciplinary team approach that’s planned and rehearsed not work or at least get the discussion started about these very sticky and difficult end-of-life issues.”

Culture connection

While many Americans approach healthcare decisions — including life and death issues — head-on, other cultures may take a different tact.

Individuals from some cultures feel that talking about death and illness depresses the patient’s resolve or will lead to additional illness. Others may believe that news of a serious illness will make other family members vulnerable to repercussions and even discrimination. Many cultures cede major health decisions to certain family members. With dozens of cultures represented by millions of recent immigrants to the U.S., how can a physician know which norms to keep in mind when breaking bad news?

Just ask, McCormick says.

“By admitting to the patient that you don’t know a lot about their culture or how they prefer to discuss health issues, you open the door for them to tell you what they want,” he says.

Where to train

Telling someone they’ve taken a turn for the worse and may not live much longer is a difficult discussion to initiate. Training helps but many of today’s practicing physicians never got the chance to learn the necessary communication skills while in medical school.

“I went to school in the 1970s and we were not trained well in things like pain management or end-of-life issues,” Old says. “I remember the first time I had to tell a family somebody had died. I didn’t know how to do it and I didn’t do it very well.”

Although more medical schools now include communication skills and other training about palliative care, many medical schools seem to give the issues little more than lip service, says Jay Bhatt, president of the American Medical Student Association.

“At a lot of schools there’s very little dedicated instruction or skills training in delivering bad news,” says Bhatt, who is scheduled to graduate from the Philadelphia College of Osteopathic Medicine in June 2007. “You kind of read about it and come across it in a geriatrics rotation or some other rotation.