Clinical Communication

Delivering Bad News in the Context of Culture: A Patient-Centered Approach

Journal of Clinical Outcomes Management. 2015 January;22(1)

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. When combined, these 2 approaches provide a framework to help the clinician communicate in a way that is patient-centered, humanistic, and culturally responsive. These approaches provide practical guidance and identify specific questions one can use to better understand the patient’s perspective of his diagnosis and treatment preferences. Additionally, the specific steps may be used over several sessions with the patient and are not necessarily meant to be done in a linear fashion.

Set Up the Interview

Before meeting with the patient, it is important to review the medical data and have a plan in mind for delivering the bad news. Schedule adequate time for discussion and avoid interruptions. Meet in a quiet, private room that is large enough to accommodate family members or friends whom the patient may have brought. In our case example, the patient has brought his wife and son to the appointment.

Doctor: Hello, Mr. Ruiz. (Turning to the patient’s wife and son) I am Dr. Simon.

Patient: Hello, Doctor. This is my wife, Maria, and son, Alejandro.

Doctor: Please have a seat. Are you comfortable?

Patient: Yes. We are anxious to hear the results of the tests.

Son: My father doesn’t always understand medical terms and I wanted to be here to help. I am very worried about him.

Doctor: I understand your concern and I will explain everything to you.

Assess the Patient’s Perception of the Problem

Before telling the patient the diagnosis, it is important to get an idea of the patient’s understanding of the problem, including what he calls it, what he thinks caused it, and how severe he thinks it is.

Doctor: Before I tell you the results, I would like to get a sense first of what you think is going on.

Patient: Well, I really don’t know for sure, but I know the pain is getting worse and I have been feeling weaker. The pain started right after my son’s wedding. There was a lot of food and I ate more than usual. Maybe it was something bad that I ate?

Doctor: (Turning to the wife and son) Do you have any thoughts about the illness?

Wife: I can see he is in pain a lot, even though he tries to hide it from me. I want to know what’s wrong. I am worried it could be something bad.

Obtain the Patient’s Invitation to Disclose the Information

It is important to know if the patient wants to be told the information about his or her diagnosis. Ideally, physicians should discuss this in general terms as part of routine care, before any bad news needs to be delivered. For example,

Doctor: There may come a time when I will need to tell you something bad about your health. Hopefully, that time will never come, but I want to know your preferences so I can honor them if the time does arise. Would you want to be told about this, or would you want someone else, perhaps someone in your family, to be told?