Telling Bad News
"A DOCTOR'S PRAYER
Before Giving a Prognosis to a Cancer Patient:
Allow me to think about the ramifications of my words before I give a prognosis to a cancer patient. Because I have seen others fail, do not let me deny this individual the right to fight. Because I have tried unsuccessfully with others, do not let me condemn this person to a sentence of hopelessness and helplessness until he succumbs. Because I am personally unaware of any treatments that could give him any relief, do not allow me to assume that there are none nor deny him the right to search. Help me use the intelligence and compassion that was given to me and help him search out the best possible resources."
From Fighting Cancer: A Step-By-Step Guide to Helping Yourself Fight CancerPhysician-Patient Communication Published by R.A. Bloch Cancer Foundation.
The telling of bad news to your patient or family is one of the severest challenges facing any physician. Learning how to do it "right" is something that cannot be learned in one day but unfortunately requires the rigors of practical experience. One of the factors which make the telling difficult is that often the physicians themselves are caught up in the emotion of the moment. The physician may feel responsible for the outcome which has lead to the telling. The physician may wish to ignore or deny to him/herself regarding the possibility that a bad prognosis will really happen. The physician, him/herself may personally identify with the bad news because of similar issue has occured in their own or their family's life. And there are other reasons. With this emotional baggage, you can understand why it is possible that the telling of the bad news is also badly done.
We teach medical students about this subject from the beginning of their education. We talk about under what conditions telling of bad news should be carried out. There are some NOTs. NOT OVER THE PHONE: The physician cannot see the expression of the patient as the news is related and the patient may not recognize the voice of the physician, there is no opportunity for the physician to physically touch the patient in a compassionate and supportive manner as if the telling was in person and there is more. NOT IN A HOSPITAL OR CLINIC HALLWAY: The communication is usually hurried because of the situation, the patient cannot sit down during the telling, there is lack of privacy and there is more. NO TELLING BY SOMEONE OTHER THAN THE PHYSICIAN: Sometimes nurses have to tell the bad news, often to family, because the physician is not around but this is usually unsatisfactory since the nurses may not be able to explain the patient's or family's questions. Physicians should arrange a quiet, private environment for the patient and physician to sit and talk. And it is important that the physician has allocated time but also mental attention for this communication so that the physician doesn't become hurried or inattentive because of reponsibilities to other patients.
A point physicians must learn is that bad news need not necessarily be communicated to the patient all at once, in one sitting. Often, partial information can be given and with time allowed for the patient to digest that information. How detailed and how fast to proceed with the telling is something a physician must decide by his/her prior knowledge of the patient and by some preliminary questions. Patients should be informed sufficiently to be able to make decisions about their illness and about their personal affairs. However, the information should be given in a manner set by the individual patient. Emotionally supportive words should be given but there should be a realistic basis for those words. Lying to the patient regarding bad news is rarely acceptable or beneficial.
There is so much more one can write and talk about this subject to medical students but as I have noted as they progress within their responsiblities and career their experiences of actually telling bad news to a patient can be their teacher.
If you would like to read two essays which will extend and develop what I have written above, I recommend that you click on them below:
Talking with Patients and
To Tell or Not to Tell