- What do Chuck Close and Dan Gottlieb have in common? Each was a healthy young adult when suddenly becoming paraplegic—Chuck from a spinal artery thrombosis, Dan from a serious accident. Each adapted to his condition. Chuck developed a unique style of painting that established his fame as an artist. Dan, a psychotherapist, became an author, teacher, and highly regarded radio interviewer. Each has recently stated that he has never been happier.
Remind yourself of hidden opportunities. Bad news triggers a crisis—an unwelcome, unstable situation with obvious danger. Less apparent is the potential for positive personal transformation and gain:
- “It was the best thing that could have happened to me,” she said, lying with her right foot propped up, ankle heavily bandaged with pins and rods protruding. “Yes, it’s a horribly fractured ankle but I had been rushing, rushing, rushing, and when I fell down the steps, it was as if an angel was forcing me to slow down, be present to my family. I really think this fractured ankle was the best thing that could have happened—it may even have saved my marriage.”
Second, cultivate yourself as a healer
You may not always be able to cure but you can always facilitate healing. In addition to a treatment plan, remind yourself to create a parallel healing plan, listing the interventions that will help the recipient integrate losses and become as functionally whole as possible.
Your ability to heal depends as much on who you are as what you do:
- Work through your own trauma stories and you reduce the likelihood that you either attempt to rescue, or flee from engagement with, patients when their problems trigger painful memories for you
- Accept your imperfections as an inseparable aspect of your humanity
- Learn to accept life as a journey, with suffering and death being inevitable, and bad news ceases to be so exceptional
- Deepen your own joy, mindfulness, and faith and you find meaning in your work even when you cannot cure
- Have realistic expectations of your abilities and try to cultivate a realistic attitude in your patients:
- In Western culture there is a belief, conscious or not, that medicine can save us from the death that lies in wait for us… In a study conducted in 2006 among Israeli doctors, 68% of the participants reported that patients had unrealistic expectations of them. The study reflects unrealistic expectations of medicine in general.8
Third, cultivate skills to break really bad news
Sometimes news is so bad, so overwhelming, that it has the potential to trigger an acute stress reaction (ASR) and even posttraumatic stress disorder (PTSD) in the recipient. Typically, this is life-threatening news—a diagnosis of HIV infection or cancer; abortion or stillbirth; or the sudden, unexpected death of a loved one. The result is shock, horror, disorientation, and memory distortion.
So how can you approach a situation in which you must offer very bad news? To begin, the box, below “Pearls for breaking bad news…,” provides a set of skills and tools for delivering bad news.
In addition, as much as possible, break bad news in increments, so that the patient has time to cope and adjust. And there is more to keep in mind:
- Provide a safe, supportive environment
- Relieve the isolation that trauma inflicts by forging a relationship that is a partnership
- Relieve helplessness by empowering and assisting the patient to seek useful consultants, resources, and supports (One example: A patient who has breast or ovarian cancer can call the SHARE [Self-help for Women with Ovarian or Breast Cancer] hotline: [866] 891-2392)
- Over time, although not initially, help provide meaning to the experience for your patient and for you.
Pearls for breaking bad news—beginning with the first telephone call or meeting
- Don’t have your assistant call with bad news unless she or he is trained to do this, humanely, and to handle the response. Don’t leave a message asking the patient to call back unless you are reasonably certain you will be able to take the call.
- Before you enter the room or place a call, pause, take a deep breath, acknowledge your feelings so you can set them aside, and be fully present. Remember: Empathy begins at home.
- Effective communication always begins and ends with listening. On entering a room, notice the people present, the atmosphere, and the interactions. Over the telephone, notice breath and tone of voice in addition to words spoken. Create space for the recipient to speak, even if silence is uncomfortably long.
- Begin the session by greeting everyone present by name and by shaking hands.
- Offer a general inquiry and listen. A simple “How are you?” allows the patient to express a feeling—“I’m OK but anxious,” for example. Respond with empathy early in the encounter: “Yes, it’s scary waiting for results.”
- Use simple, nontechnical language to describe the situation. Be brief, because a person in a high state of arousal has limited capacity to absorb details. Avoid harsh language (“aggressive,” “failure”) and use a calm, modulated tone.
- Listen and validate the responses you get, recognizing that you may be the recipient of an entire spectrum of emotional expression—from silence to an outburst of anger, from rage to grief. Keep in mind: Anything said in grief is acceptable.
- Remember: You are not responsible for your patients’ happiness. When a patient cries, it does not mean that you failed. An outpouring of grief is healing; your silent, supportive presence is invaluable.
- Don’t attempt to prematurely comfort; don’t try to “make it better,” because this stifles grief. Offering a box of tissues, on the other hand, is simply considerate.
- Don’t present the bleakest scenario. Later, as the patient adapts to her new reality, she will usually be able to tolerate more.
- Be forearmed with some basic treatment and referral options so that the patient isn’t left facing the dark unknown.
- Now, invite the patient’s perspective. Appreciate that she may be experiencing a sea of emotions, especially if the news is totally unexpected. It’s not sufficient to lay out options, then leave the final decision to her. Part of decision-making involves the processing of emotions. Gendlin’s technique of focusing is very useful at this point in the conversation.1
- If you are at the hospital, 1) consider having a chaplain present when the news is potentially devastating and 2) attend to privacy concerns when breaking bad news.
- Treat the person, not the pathology. Ask about her work, activities, and circle of support—all of which are relevant to her situation.
- Be clear that you will remain actively involved in her care even after you refer the patient to the best consultants available.
- Don’t limit yourself to the negative. Look for what is healthy about your patient’s situation, too, and support it.
- Give as much information as possible in writing at this time; amnesia is common. Offer to share the information with at least one family member over the telephone, or schedule a second visit at which a relative will be present.
- When you’re questioned directly, give yourself the benefit of a few moments to ground yourself before you respond.
- Ensure a safe exit for your patient. Does she have someone to drive her, keep her company, etc.?
- Consider calling her that evening to see how she is and to answer any additional questions.
- Invest in self-care. This might include debriefing, taking a break between patients for integration, and grounding and rituals that enable you to detoxify after a difficult day. Cultivate whatever spiritual and meditative practices are part of your life, even if it is simply a walk in the park.
- Empower yourself with relationship skills that enhance your ability to communicate and counsel.
- Have faith! The time that you invest in healthy practice and communication will save you much more over the course of your career.
Reference
1. Bub B. Communication skills that heal: a practical approach to a new professionalism in medicine. Abingdon, UK: Radcliffe Publishing; 2006.