Fast Fact and Concept #006; Delivering Bad News Part I

2nd Edition

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

Case Scenario: You are caring for a previously healthy 52 y/o 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?

• Create an appropriate physical setting: A quiet, comfortable room, turn off beeper, check personal appearance, have participants, including yourself, sitting down.
• Determine who should be present? Ask the patient whom they want to participate--clarify relationships to patient. Decide if you want others present (e.g. nurse, consultant, chaplain, social worker) and obtain patient/family permission.
• Think through your goals for the meeting as well as possible goals of the patient.
• Make sure you know basic information about the patient’s disease, prognosis, treatment options.
• Special circumstances: Patient not competent (developmentally delayed, dementia, etc.) Make sure legal decision-maker is present.
• Special circumstances: Patient doesn’t speak English. Obtain a skilled medical interpreter if the patient or family do not speak English. Use ATT translation service or other phone service is necessary.

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. As a preceptor, you will want to support the resident. Key teaching points:

• Residents may not spontaneously discuss their own emotional reaction with a preceptor, therefore you will want to introduce this topic. “This is a really hard case, how are you doing?”
• Physicians often have strong emotional reactions when a patient encounters bad news. Normalize the experience for the resident; “Its normal to have strong feelings”.
• Three methods for coping with these feelings: Identify your feelings (anger, sadness, fear, guilt); Talk with a colleague; Keep a personal journal.

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. 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. Galen Press, Inc., Tuscon, Arizona, 1999.
4. Ptacek, JT, Eberhardt, TL. Breaking bad news: A review of the literature. JAMA, 157:323, 1996.
5. Sim, I. How to give bad news. http://www-med.stanford.edu/school/DGIM/Teaching/Modules/badnews.html
6. Quill TE. Bad news: delivery, dialogue and dilemmas. Arch Intern Med 1991; 151:463-468.
7. Girgis A and Sanson-Fischer RW. Breaking bad news: consensus guidelines for medical practitioners. J Clin Onc 1995;13:2449-2456.
8. 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 were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu