Portal de Periódicos da CAPES

How to Break Bad News—And Not Devastate the Patient

1994; Elsevier BV; Volume: 69; Issue: 10 Linguagem: Inglês

10.1016/s0025-6196(12)61833-3

1942-5546

Edward T. Creagan,

Patient Dignity and Privacy

The ability to share bad news compassionately with the patient and the family is crucial from several perspectives. First, this task is not optional and cannot be legitimately delegated to a surrogate. It is the physician's responsibility to share with the patient the implications of a fatal diagnosis. When patients are told the truth, they have an opportunity to deal with practical and business responsibilities, establish a meaningful, emotional exchange with loved ones, and establish a realistic basis for emerging clinical developments that will be shared with the physician. Second, legal precedents mandate that patients be informed about the nature and implications of their illness. Third, if this task is done deftly and tactfully, the effectiveness and satisfaction of a patient-physician relationship can be enhanced substantially. Briefly, this responsibility cannot be short-circuited or avoided. Why is sharing bad news with the patient so painful, uncomfortable, and sometimes awkward? The main focus of the American consciousness continues to emphasize health, wealth, and youth. The need to “hang on to” these qualities is insatiable despite the obvious reality that people in their 80s are the most rapidly increasing segment of the American population. Any serious illness is obviously a threat to health and, indirectly, a threat to one's youthful vitality with associated economic implications. Illness is not only costly in terms of out-of-pocket expenses but also may profoundly affect one's ability to be gainfully employed. Being blamed for a misadventure or a misfortune is not pleasant. Unfortunately, the messenger of bad news may receive the brunt of the patient's ire and the wrath of the family even though the messenger was not directly involved in the incident. We live in an increasingly litigious society, and the emerging tendency is to seek legal redress for perceived medical care inadequacies. In many circumstances, a knee-jerk reflex is to blame “somebody,” and often this situation has profound legal implications. In addition, physicians may have difficulties dealing with the anger, despair, denial, and other emotions often expressed by the patient and by the family. Breaking bad news to the patient and the family may be viewed as a diagnostic or a therapeutic failure. This phenomenon may challenge the essence of how physicians view themselves. If they view themselves as omnipotent dispensers of health or are viewed as such, their sense of worth will be challenged by bad news. If, however, they view themselves as a partner with the patient against illness, breaking bad news is far less stressful. One or two generations ago, a fairly typical situation in the United States was for the extended family to live together as a social unit. Usually, this consisted of multigenerations that involved grandparents, parents, and children, either living in one home or in one relatively confined geographic area such as a farm or a small rural community. Children observed parents and grandparents age, and they recognized and perhaps even participated in the death of a parent or grandparent. Death was part of the natural cycle. Today, however, because of the dispersal and fragmentation of the American family and the institutionalization of elderly persons, many people reach adulthood without being exposed to an elderly person or to death. Breaking bad news may be especially stressful because of the occasional unrealistic expectations from current medical practice. On an almost daily basis, the media boast about major medical or surgical breakthroughs, and the inclination to extrapolate those experiences to all medical illness may be natural. This projection is unrealistic but nevertheless happens. Somehow, the belief is that each of us will indeed live forever, but when illness strikes, hopes and expectations are dashed. In our secular society, conspicuous consumption and materialism are often the measure of a person's worth and purpose. Illness, especially a chronic condition with fatal implications, may threaten one's social and economic status. In addition, the physician has increased responsibility due to the changing position of religion in society. At one time, substantial segments of the population had a generally uniform belief in a “Higher Power” and a sense of the afterlife. Often, physicians could call on that source of communal strength and purpose to sustain families during times of bereavement. An outpouring of community support in conjunction with the loving concern of members of the religious community was of considerable help to the physician in breaking bad news to the family. Those types of communities shared the responsibility, and the physician was far less accountable as the messenger of doom. Today, however, the traditional religious denominations have undergone tremendous change, and the physician cannot always be certain that the patient's religious orientation will be sustaining during a time of crisis. At one time, a priest, rabbi, or minister was an integral aspect of the family and social fabric, and the inclusion of clergy was entirely appropriate. Today, however, the physician may be on perilous ground if that type of assumption is made. Hundreds of scenarios on sharing bad news can be played out, and the following comments provide some generic guidelines for physicians. If possible, sit down with the patient and the responsible family members when bad news is being shared. Studies have shown that patients perceive a physician who is sitting as more caring and concerned in comparison with a physician who is standing, even though the amount of time spent with the patient is exactly the same. Eye contact is crucial, and mechanical barriers such as nightstands, feeding tables, and intravenous poles should not be in the line of vision. Discussions must be held in a private area where orderlies, security personnel, or passersby cannot interrupt. The physician must know who is with the patient and what the relationship is. One cannot assume that the woman with the male patient is a wife or mother nor that the gentleman with the female patient is a son or husband. The issue of confidentiality is crucial. Patients should be asked who they wish to have participate in these difficult discussions. The presence of a relative or friend can imply the patient's consent. This issue should be clarified before prognosis and treatment options are discussed. In addition, the physician should speak slowly, sense that the patient and family are understanding the information, and allow the patient and family time to absorb the implications of the diagnosis. No assumptions can be made about what the patient knows. Many patients are initially informed about the diagnosis of cancer postoperatively when they are receiving sedatives and narcotic agents and are still recovering from the effects of anesthesia. Possibly, a consulting medical oncologist is the first professional to enlighten the patient about the implications of the current situation. Providing detailed information is futile and counterproductive if the patient is tired or in pain. One way to handle this delicate situation is to offer a few introductory comments with the notion of returning soon. If the patient is a nurse, physician, attorney, or Ph.D., no assumptions can be made about the patient's level of understanding. Some physicians and nurses with cancer have been misled about the implications of their diagnosis because of unwarranted assumptions by the oncologist. A reasonable approach is to begin the discussion as one would with a nonprofessional but clearly invite questions and clarifications as the discussion proceeds. How much detail the physician gives to the patient is considerably personal and varies with the situation. Patients should have a general overview of their condition in terms of anticipated natural history or a “ballpark figure” about duration of survival; however, each patient is an individual, and statistics and probabilities apply only to groups of patients. Most patients can absorb only small amounts of bad news; thus, periodic visits with the patient are important, and more light can be shed on the problem with each encounter. The patient has the right to know the diagnosis and its implications in understandable medical terms. The prognosis in terms of survival can be addressed in generalities; discussions about treatment options are important. During a brief encounter, providing substantial detail about all the side effects of treatment is unnecessary, but discussing some of the more commonly anticipated problems such as hair loss, nausea, and vomiting associated with chemotherapy is important. Asking periodically, “Am I making sense?” is helpful because most patients are reluctant to interrupt when they do not understand a medical conversation, especially during a time of stress. Feelings of shock, anger, guilt, frustration, depression, and rage are normal during this painful time. Discounting the patient's feelings is inappropriate; their emotions should be recognized and validated. Because many patients will be embarrassed if they cry, a moment or two of quiet silence is helpful. The physician can acknowledge that the patient's reaction is relevant and perhaps touch the patient's hand. When confronted with the diagnosis of a malignant disease, many patients become almost overwhelmed with tremendous feelings of uncertainty. A general framework of follow-up is crucial. The time intervals for surveillance and scheduled revisits should be addressed at this time. The patient should be reassured that something can be done even if traditional anticancer therapies are inappropriate because of side effects or lack of benefit, that options and alternatives are available, and that contingencies are based on clinical circumstances. The following questions are commonly asked by patients with cancer. 1.How long will I live? A clumsily worded response can tremendously affect the patient and the family. The physician must carefully measure the response. Mentioning the disclaimer (as is recognized by most patients) that no magic formulas exist for duration of survival for any individual patient is important. One reasonable way of answering the patient's question might be as follows: “In your specific case, no definite answer is available about the duration of survival. In groups of patients with your type of cancer, however, survival may range from several weeks to several months; survival for several years is unlikely. Nevertheless, small groups of patients with your type of disease have meaningful and productive lives for reasons that are not understood. Close follow-up and careful monitoring at periodic intervals will help in determining problems and in dealing with them as they arise.” The use of firm numbers should be avoided if possible because family members can distort or misunderstand their meaning.2.Is my condition terminal? This question is common. A gentle redefinition of the word “terminal” seems reasonable. Ask the patient what is meant by the term “terminal” because the patient's definition might differ from that of the physician. Personally, I avoid the reply, “Well, we are all terminal” because this statement seems somewhat demeaning to the patient. State that it is highly likely that, in the future, the cancer will cause problems but measures may be available to enhance quality of life and comfort.3.What will it be like? Obviously, this question is “loaded.” Again, the physician can ask the patient what exactly is meant by this question. “What concerns you? What is the overriding problem that troubles you relative to the cancer?” Some patients are indirectly asking about abandonment, neglect, and being sent home “because nothing more can be done.” Some measure can be offered to enhance dignity during the progression of the malignant process. Circumstances may arise during a physician's career in which meeting with the family is not possible. One awkward situation is when the patient dies in the hospital and the family is not there. Some general guidelines that may be helpful for physicians in this clumsy situation are as follows. 1.Be certain to know who answers the telephone. This aspect is most important if discussions are held during the early morning hours or late at night when family members may be exhausted; the possibility for miscommunication is tremendous. Know the relationship of the person on the telephone to the patient and to the family.2.Introduce yourself especially if you have been only peripherally involved with the patient, a common situation on a busy inpatient service. Ascertain that the family knows who you are and how you are involved with the health-care team.3.Speak slowly and deliberately, particularly at night.4.Be certain that your opening statement is not a bludgeoning salvo that takes the family completely off guard. A warning can help the family slowly recognize the seriousness of the telephone call. An example of an introductory statement is as follows: “My name is Dr. X. I am one of the cancer specialists who have been caring for Mrs. Y. Some serious developments have occurred during the past few hours, and I am saddened to bring you bad news.” This type of introduction allows the family a moment or two to adjust to the situation. If the patient has died, the family should be told. The terminology “has died” seems more humane than the concept of “is dead.” Under most circumstances, inviting the family to the hospital with the belief that the patient is still alive is dishonest and can create ill will.5.Offer to contact other family members, clergy members, or neighbors, especially if the person being called is alone or if the telephone call is during the middle of the night. If you sense that the family member does not understand the seriousness of the problem, ask to speak to another family member, a neighbor, or a clergy member. Sharing bad news is both an art and a science. If possible, the bearer of bad news should sit with the patient in a comfortable and dignified atmosphere that is free of distractions and interruptions. The physician should use simple, straightforward, and concise language with no technical jargon or complex medical terminology. Small pieces of information delivered over a period of time seem to be more readily absorbed by most patients rather than a bolus of bad news. Numeric specifics of survival, odds, and probabilities should be avoided because they may be rigidly interpreted by the patient and family. Some element of hope, no matter how remote, is important, as is an emphasis on options and alternatives that, although not curative, can be palliative and can enhance the quality of life.