Breaking bad news is not something that most medical students are eager to try. Dilbert's advisor Dogbert says: "Never break bad news...it will only get you in trouble." And stories abound about how unskilled physicians blundered their way through an important conversation, sometimes resulting in serious harm to the patient. Many patients with cancer, for example, can recall in detail how their diagnosis was disclosed, even if they remember little of the conversation that followed, and they report that physician competence in these situations is critical to establishing trust.
Some physicians contend that breaking bad news is an innate skill, like perfect pitch, that cannot be acquired otherwise. This is incorrect. Physicians who are good at discussing bad news with their patients usually report that breaking bad news is a skill that they have worked hard to learn. Furthermore, studies of physician education demonstrate that communication skills can be learned, and have effects that persist long after the training is finished.
Robert Buckman's Six Step Protocol for Breaking Bad News
Robert Buckman, in an excellent short manual, has outlined a six step protocol for breaking bad news. The steps are:
- Getting started.
The physical setting ought to be private, with both physician and patient comfortably seated. You should ask the patient who else ought to be present, and let the patient decide--studies show that different patients have widely varying views on what they would want. It is helpful to start with a question like, "How are you feeling right now?" to indicate to the patient that this conversation will be a two-way affair.
- Finding out how much the patient knows.
By asking a question such as, "What have you already been told about your illness?" you can begin to understand what the patient has already been told ("I have lung cancer, and I need surgery"), or how much the patient understood about what's been said ("the doctor said something about a spot on my chest x-ray"), the patients level of technical sophistication ("I've got a T2N0 adenocarcinoma"), and the patient's emotional state ("I've been so worried I might have cancer that I haven't slept for a week").
- Finding out how much the patient wants to know.
It is useful to ask patients what level of detail you should cover. For instance, you can say, "Some patients want me to cover every medical detail, but other patients want only the big picture--what would you prefer now?" This establishes that there is no right answer, and that different patients have different styles. Also this question establishes that a patient may ask for something different during the next conversation.
- Sharing the information.
Decide on the agenda before you sit down with the patient, so that you have the relevant information at hand. The topics to consider in planning an agenda are: diagnosis, treatment, prognosis, and support or coping. However, an appropriate agenda will usually focus on one or two topics. For a patient on a medicine service whose biopsy just showed lung cancer, the agenda might be: a) disclose diagnosis of lung cancer; b) discuss the process of workup and formulation of treatment options ("We will have the cancer doctors see you this afternoon to see whether other tests would be helpful to outline your treatment options"). Give the information in small chunks, and be sure to stop between each chunk to ask the patient if he or she understands ("I'm going to stop for a minute to see if you have questions"). Long lectures are overwhelming and confusing. Remember to translate medical terms into English, and don't try to teach pathophysiology.
- Responding to the patients feelings.
If you don't understand the patient's reaction, you will leave a lot of unfinished business, and you will miss an opportunity to be a caring physician. Learning to identify and acknowledge a patient's reaction is something that definitely improves with experience, if you're attentive, but you can also simply ask ("Could you tell me a bit about what you are feeling?").
- Planning and follow-through.
At this point you need to synthesize the patient's concerns and the medical issues into a concrete plan that can be carried out in the patient's system of health care. Outline a step-by-step plan, explain it to the patient, and contract about the next step. Be explicit about your next contact with the patient ("I'll see you in clinic in 2 weeks") or the fact that you won't see the patient ("I'm going to be rotating off service, so you will see Dr. Back in clinic"). Give the patient a phone number or a way to contact the relevant medical caregiver if something arises before the next planned contact.
What if the patient starts to cry while I am talking?
In general, it is better simply to wait for the person to stop crying. If it seems appropriate, you can acknowledge it ("Let's just take a break now until you're ready to start again") but do not assume you know the reason for the tears (you may want to explore the reasons now or later). Most patients are somewhat embarrassed if they begin to cry and will not continue for long. It is nice to offer kleenex if they are readily available (something to plan ahead); but try not to act as if tears are an emergency that must be stopped, and don't run out of the room--you want to show that you're willing to deal with anything that comes up.
I had a long talk with the patient yesterday, and today the nurse took me aside to say that the patient doesn't understand what's going on! What's the problem?
Sometimes patients ask the same question of different caregivers, sometimes they just didn't remember it all, and sometimes they need to go over something more than once because of their emotional distress, the technical nature of the medical interventions involved, or their concerns were not recognized and addressed.
I just saw another caregiver tell something to my patient in a really insensitive way. What should I do?
First, examine what happened and ask yourself why the encounter went badly. If you see the patient later, you might consider acknowledging it to the patient in a way that doesn't slander the insensitive caregiver ("I thought you looked upset when we were talking earlier and I just thought I should follow up on that--was something bothering you?")