11 October 2016

Giving Patients Bad News: An Eight-Step Approach for Hospital Physicians

Communicating difficult news to patients and their families is one of a physician’s most uncomfortable duties. Physicians’ medical training and professional commitment both focus on curing patients’ conditions and improving or preserving their quality of life. So having to tell a patient that there is nothing more to be done medically can leave a doctor feeling as helpless as the patient and family. Despite knowing intellectually that everything that could have be done to help the patient was done, the doctor still may experience feelings of having failed that patient. And delivering bad news can be even harder for a hospital physician who doesn’t have a longstanding, trusted relationship with the patient.

Effective patient communication is an increasingly essential skill for physicians, yet few have received training or coaching in this area.  As a result, doctors often feel less confident than usual when they need to communicate a negative prognosis to patients and their families, making this difficult task even harder. 

The following framework (adapted in part from an earlier six-step approach published in Family Practice Management) can help hospital physicians communicate difficult news clearly and compassionately.

How to Deliver Bad News to Patients and Their Families

  1. Be as Prepared as Possible. Preparing and planning for a difficult discussion with a hospital patient isn’t always possible, such as in emergency situations. But doing things like finding a quiet, private location for the conversation where there will be no interruptions, arranging for an interpreter, if appropriate, and asking whom the patient wants to be present for the discussion can help keep a very difficult patient experience from being even harder.
  2. Assess the Patient’s Understanding. Asking the patient to share their understanding of their medical condition provides a starting point for the conversation that the physician can build on in Step 4. Consider adding any additional relevant information in the patient’s medical records to provide context for what you are about to tell them. 

  3. Warn That Bad News Is Coming. Don’t tell them what it is yet, just give the patient (and family, if present) a brief heads-up so they can prepare themselves to hear unwanted news.

  4. Deliver It Simply, Clearly and Straightforwardly. Be as brief as possible at this point, especially if the news is likely to be unexpected. Unless your patient is very familiar with the medical terms and jargon related to his or her condition, avoid using them and substitute simpler, more common words that the patient and family can understand more easily. This is especially important when communicating bad news in a language other than the patient’s and/or family members’ native tongue. 

  5. Provide Time and Space to React. After briefly communicating the bad news, stop talking. Give the patient and family members some time and “emotional space” to process what they’ve just heard and then react to it. Observe and listen attentively, quietly, and respectfully as they express their initial reactions – shock, anger, sadness, denial or other emotions. Acknowledge the difficulty of the situation and express your sympathy and compassion. 

  6. Avoid Information Overload. If no questions have been asked yet, ask the patient and family what else they would like to know. As you answer each question, gauge their reactions to help you determine how much detail to provide. Continue monitoring the reactions and body language to help you gauge how much more information, if any, to add once those questions have been answered. Consider preparing a summary of key points and a handout of supplementary information and resources prior to the discussion so the patient and family members can review and refer to them after the discussion, when they have had more time to process the bad news and other information they just received. 

  7. Let Them Know What’s Ahead. Describe the likely progression of the patient’s disease or condition. Explain any choices that may be available in terms of next steps, such as alternative or experimental therapies, chronic pain management techniques or palliative care, if applicable. 

  8. Connect Them to a Care Coordinator or Adviser. To make sure the patient and family don’t feel abandoned during this difficult time, make advance arrangements for them to meet with someone who can help coordinate and connect them with appropriate support resources within and/or outside the hospital. 

Take Care of Yourself, Too

Delivering bad news to anyone, especially someone in your care, is a difficult responsibility. For doctors who must deliver bad news to patients frequently, it can be a significant contributor to physician burnout. Talking about this stressful experience and sharing your thoughts and feelings about it can be extremely helpful, so don’t hesitate to seek advice, counseling or just a sympathetic ear from someone who has been in the same position. 

Find more insights on communicating with patients more effectively in our blog post on Six Physician Communication Strategies to Increase Patient Engagement and Improve Outcomes.