TAMPA – Sharing bad news with patients might not be easy, but it’s a skill physicians can learn and as important as knowing how to ready an EKG or an x-ray, James A. Avery, MD, CMD, said.
"What I am proposing is that giving bad news well is a fundamental long-term care physician skill, and competence in this area is critical," Dr. Avery said at this year’s AMDA – Dedicated to Long Term Medicine annual meeting.
Dr. James A. Avery
"Giving bad news ... takes desire, courage, and practice," said Dr. Avery. "Patients deserve to get bad news delivered with compassion, hope, and integrity."
Plan ahead for the conversation; start with what the patient knows and wants to know; and develop a compassionate tone, said Dr. Avery, chief medical officer at Golden Living in Washington, a corporation that focuses on skilled nursing, assisted living, and rehabilitation therapy. Also, always provide an appropriate prognosis. "It’s your obligation to bring this up. Patients and families may be afraid to ask."
What can happen if the conversation is not done correctly? "If bad news is given poorly, it can rob hope and create distress, confusion, and anxiety. It can weaken the patient’s faith and set off a chain of events that adversely affects the survivors for years," said Dr. Avery.
"I was particularly bad at giving bad news at first," he said. A pulmonologist by training, he also worked for years in hospice care in both Florida and New York. He spoke with patients who transitioned to hospice from Memorial Sloan-Kettering Cancer Center, for example.
"I learned quickly that if I was going to give bad news, not to schedule the patient for midmorning on a Monday. It is too chaotic," Dr. Avery said. Schedule the patient for the first appointment after lunch or at the end of the day. Allow sufficient time and create a comfortable, private place with tissues available, he added.
Next, determine where each patient is in terms of understanding his or her illness. "Explore and ask," Dr. Avery said. Good questions include:
- Is there anyone else you want to have in the conversation?
- How do you understand what has happened to you medically?
- What have doctors told you about this illness?
- What do you think caused this illness?
"I cannot tell you how many patients with colon cancer thought they had it because they took too many antacids," Dr. Avery said. "Also, I had one woman with breast cancer who responded ‘Burger King.’ She had read an article that fatty foods caused breast cancer. She had guilt that she was leaving her family because she ate burgers instead of salads."
Also, determine how much the patient wants to know. "About 90% of patients want full information [about their condition], but everyone wants to know everything about treatment." Physicians also can be instrumental in allaying end-of-life fears, Dr. Avery said. Regardless of illness, most patients think some symptom is going to get worse and worse and crescendo in pain before they die. "How do people with [chronic obstructive pulmonary disease] die? Yes, the symptoms get worse, but with COPD, they get COPD narcosis, get sleepy, and drift away."
Intentionally develop and use a compassionate tone, Dr. Avery said. This is important because patients surveyed after they received bad news said the attitude of the person who spoke with them was the most important factor. The clarity of the message and privacy were also important, but they ranked far behind clinician attitude, he said.
Allow for silence. Let the message to sink in. "Give the patient plenty of time to react, respond, and ask questions." Also allow tears – "That can be a real problem for a lot of doctors."
A challenge for physicians is to be empathetic without breaking down completely, Dr. Avery said. When working in hospice care in New York, he frequently spent the day traveling by subway to clients’ residences. "Am I going to travel around weeping? No. You have to somehow try to meet where they are, but you cannot go there completely. It would be self-destructive."
"One reason physicians think they do not give bad news well is they fear their own response; that they will break down," Dr. Avery said. Try to determine the patient’s attitude and reflect it back to them. "This is what you do when things get emotional. And they will correct you if you’re wrong. If you say ‘You sound angry,’ they might say ‘No, I’m upset.’"