# 006 Delivering Bad News-Part 1, 2nd ed

FAST FACTS AND CONCEPTS #006 PDF


Author(s): Bruce Ambuel PhD and David E Weissman MD

Case Scenario: You are caring for a previously healthy 52 year old man with a new problem of abdominal pain. After conservative treatments fail, a diagnostic abdominal CT scan is done showing a focal mass with ulceration in the body of the stomach and numerous (more than 10) densities in the liver compatible with liver metastases. The radiologist feels that the findings are absolutely typical of metastatic stomach cancer. How do you prepare to discuss these test results with the patient?

Preparing to Delivery Bad News

  1. Create an appropriate physical setting: a quiet, comfortable room, turn off beeper, check personal appearance, have participants – including yourself – sitting down.
  2. Determine who should be present. Ask the patient who they want to participate and clarify their relationships to the patient. Decide if you want others present (e.g. nurse, consultant, chaplain, social worker) and obtain patient/family permission.
  3. Think through your goals for the meeting as well as possible goals of the patient.
  4. Make sure you know basic information about the patient’s disease: prognosis, treatment options, next steps.
  5. Special circumstances: If the patient lacks decision-making capacity (e.g. developmentally delayed, demented, delirious, etc.), make sure the legal decision-maker is present.
  6. Special circumstances: If the patient or family do not speak English, obtain a skilled medical interpreter. Use phone translation services if necessary. See also Fast Fact #154.

Precepting self-reflection Residents will invariably have strong emotions when they have to give bad news. This emotional response can be heightened by various factors—a young patient, an unexpected diagnosis, a patient with whom the physician has a long-standing relationship, etc. Preceptors need to support the resident. Key teaching points:

  1. Residents may not spontaneously discuss their own emotional reaction with a preceptor, therefore preceptors need to introduce this topic. “This is a really hard case, how are you doing?”
  2. Physicians often have strong emotional reactions when a patient encounters bad news. Normalize the experience for the resident. “It’s normal to have strong feelings”.
  3. Three methods for coping with these feelings are: Identify your feelings (anger, sadness, fear, guilt); Talk with a colleague; Keep a personal journal.
  4. Role play the discussion with the resident before you go into the room; ask them to reflect on how it “feels”…what is hard…what is easy. Encourage continued self-reflection.

See related Fast Facts: Delivering Bad News Part 2 (#11); Death Pronouncement (#4); Moderating a Family Conference (#16); Responding to Patient Emotion (#29); Dealing with Anger (#59).

References

  1. Buckman R. How to break bad news: A guide for health care professionals. Baltimore, MD: Johns Hopkins University Press; 1992.
  2. Faulkner A. Breaking bad news – a flow diagram. Palliative Medicine. 1994: 8;145-151.
  3.  Iverson, VK. Pocket protocols—Notifying Survivors About Sudden, Unexpected Deaths. Tuscon, AZ: Galen Press; 1999.
  4. Ptacek, JT, Eberhardt, TL. Breaking bad news: A review of the literature. JAMA. 1996; 276(6): 496-502.
  5. Quill TE. Bad news: delivery, dialogue and dilemmas. Arch Intern Med. 1991; 151:463-468.
  6. Girgis A, Sanson-Fischer RW. Breaking bad news: consensus guidelines for medical practitioners. J Clin Onc. 1995; 13:2449-2456.
  7. Von Gunten CF, Ferris FD and Emanuel LL. Ensuring competency in end-of-life care: Communication and Relational Skills. JAMA. 2000; 284:3051-3057.

Fast Facts and Concepts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published July 2005. Current version re-copy-edited March 2009.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Ambuel B, Weissman DE. Delivering Bad News – Part 1, 2nd Edition. Fast Facts and Concepts. July 2005; 6. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_006.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

ACGME Competencies: Interpersonal and Communication Skills, Patient Care

Keyword(s): Communication