When the news is bad

June 17, 2005

When you convey life-changing information to patients, what you say and how you say it is all-important.

Recently, the Medical College of Ohio in Toledo received a $1.9 million gift, with the stipulation that it be used to teach medical professionals interpersonal skills. The gift came from the estate of Ruth M. Hillebrand, who died of mesothelioma in 1994. Hillebrand learned of her terminal diagnosis via a brief, late-night telephone call from a physician she scarcely knew.

There's no standard way to convey bad news; much depends on the patient's age, ability to process the information, anticipated response, and psychosocial needs. Still, certain "rules" apply. Knowing them won't necessarily make the sad task of delivering bad news easier, but you might be able to allay your patient's distress-and your own.

Hope for the best, prepare for the worst "Sensitive discussions with patients don't occur in a vacuum," says pediatrician Gerald B. Hickson, director of the Vanderbilt University Medical Center's Center for Patient & Professional Advocacy in Nashville. "They occur in the context of everything that has gone on before and that set the stage for effective communication, or for distrust and suspicion.

Don't convey the bad news via e-mail or voice mail, either, and don't leave the task to a subordinate (see the article). Ask the patient to come to your office after hours. "Patients want a clear message, compassionately delivered," says internist Geoffrey H. Gordon, former associate director of clinical education at the Bayer Institute for Health Care Communication, based in New Haven, CT.

Other important principles:

Prepare yourself before talking to the patient. "We advise medical students and physicians to, figuratively, take their own pulse before delivering bad news," says Gregory Makoul, who directs the Program in Communication & Medicine at Northwestern University's Feinberg School of Medicine in Chicago. "That is, make sure you're focused, and know what you want to say and how you want to say it."

If the patient has an illness you don't know much about, make sure you get up to speed before you see him. "A quick Internet search, a chat with the medical librarian to get relevant articles, or a curbside consult with a specialist will help you understand the condition well enough to explain it to the patient," advises Elizabeth Pector, an FP in Naperville, IL. "Find out who cares for the condition locally, or get a specialist's recommendation for the best tertiary care center to deal with the disease."

Deliver the news in a timely fashion. As soon as you've gathered the necessary information, call the patient and ask her to come in. "We all try to put off unpleasant duties, but in this case there are two good reasons not to," says Eric E. Shore, an internist and attorney in Bala Cynwyd, PA. "First, waiting can cost the patient valuable time in beginning treatment. Second, a delay can trigger suspicion that you're trying to cover something up, and lead to the anger and resentment that are often followed by litigation."

Have a support person present. "A second pair of ears ensures your words are heard twice," says Pector. "The support person knows the patient better, and can ask questions for a shocked individual who can't think straight."