Originally published March 2015
One of physicians’ most difficult duties is to give patients bad news about their health or prognosis. Even with significant advances in medical education on communication in end-of-life discussions, many doctors do not always feel sufficiently prepared for this daunting task. The unease of the situation may cause physicians to avoid having meaningful discussions or communicating adequately with patients diagnosed with a terminal illness and with their families (when appropriate). Failing to communicate effectively can sometimes lead to unwanted consequences such as invasive procedures, rather than focusing on comfort and support for the patient. This, in turn, may precipitate otherwise avoidable complaints and legal actions against physicians.
A recent study identified 11 key elements of end-of-life care discussions with seriously ill patients in hospital.1 These include, for example, disclosing the prognosis and asking about the patient’s values in the context of healthcare decisions. They also include providing information about expected outcomes, and the risks of life-sustaining treatments and comfort measures. Patients reported that on average only 1.4 of the 11 elements had been discussed during the first few days of being admitted to hospital, and 10% of patients were not told their prognosis.
By preparing for a discussion of bad news, considering how to deal with patients’ reactions, and dealing with their own emotional health, physicians can communicate effectively with patients and their families when a patient’s prognosis is terminal. This can help patients make informed choices that are consistent with their values and that contribute to quality end-of-life care.
Preparing to share the news
Starting a dialogue early — when definitive test results are known and the physician has made a final diagnosis — is important for helping patients face a terminal illness.
- Rehearse how you will deliver the information. If your experience in delivering bad news is limited, consider observing a more experienced colleague or use role play to practise different scenarios.
- Schedule the discussion in a private, comfortable location. Allow sufficient time, free of interruptions. When possible, and with the patient’s permission, have a family member, caregiver, or substitute decision-maker attend.
- Have the patient’s medical record, including diagnostic results, on hand.
- Be prepared to provide as much information as a reasonable patient would want and need to know.
Dealing with patient reactions
Doctors may want to prepare the patient and family for the news by saying, “I have received the test results and we need to talk. I’m sorry, but I have bad news.” Physicians need to be candid but compassionate, and the information should be presented in a well-organized manner using plain, non-technical language. The literature offers suggestions for language that may be employed.2,3 At all times, it is important to be sensitive to patients’ personal and cultural values, and spiritual or religious beliefs.
Most patients need time to process difficult news, and physicians should be prepared for emotional reactions including shock and distress. The discussion should proceed at the patient’s pace and according to the patient’s emotions. It is also important to listen and to give patients and their family opportunities to ask questions. Supplying written material such as patient aids may help patients better understand their clinical situation.
After having time to absorb the news from the initial discussion, patients and families may request follow-up discussions. During these subsequent discussions, patients should be given the opportunity to ask additional questions, and physicians should be ready to repeat the information or provide more details. At such follow-up meetings, the goals of care, treatment options, and end-of-life preferences should be discussed. The goals of care should be routinely assessed over time and remain focused on compassion and the needs of the patient. The patient’s emotional state should be closely monitored. In addition to communicating with the patient and family, when appropriate, the most-responsible physician should also communicate relevant information to the care team. These discussions and actions should be documented in the medical record.
Maintaining hope is crucial for many patients. When a cure is not a likely outcome, hope may be focused on achieving comfort and quality of life. Patients will want to know about their options for palliative care, and families may want to seek available community-based support. This may also be a good time to talk with the patient about whether they want spiritual support and to direct them to resources, as appropriate. The patient needs to know that the physician cares and will provide the necessary support or find resources to do so.
Physicians need support, too
Physicians should be attentive to their own emotions during and after difficult discussions with patients and families. Physicians who feel overwhelmed or stressed may benefit from speaking with a sympathetic colleague, or contacting their provincial physician health program, which can offer individual counselling and support. As physicians’ emotional response continues after work, sharing their feelings with their loved ones, without divulging personal patient information, can also help.
The bottom line
Physicians’ attitudes and ability to communicate are essential in helping patients cope with difficult news.
- Remain sensitive to the patient’s cultural values and spiritual beliefs, which may help guide how much information a patient wants about their condition. Nevertheless, patients should have sufficient information to enable them to assess their options and make informed decisions about their care and plan the end of life.
- Determine patient understanding of the information being provided, and answer questions honestly and openly. Address any language, cultural, or cognitive barriers to effective communication.
- Demonstrate empathy and support to the patient and family.
- Document the consultations and communication in the medical record.
- Physicians concerned about their exposure to medico-legal difficulties are encouraged to contact the CMPA for advice and assistance.
- You, John, Dodek, Peter, et al., “What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families.” Canadian Medical Association Journal, 2014, 1-9. Accessed November 4, 2014 at: http://www.cmaj.ca/content/early/2014/11/03/cmaj.140673
- Pantilat, S., “Communicating with Seriously Ill Patients: Better Words to Say,” Journal of the American Medical Association (2009) Vol. 301, No.12, p.1279-1281
- Workman, S., “A communication model for encouraging optimal care at the end of life for hospitalized patients,” Quarterly Journal of Medicine (2007) Vol. 100, p.791-797