How to Tell the Bad News: Telling It First or Telling it Last?

An issue in practice for all physicians is how to tell the patient bad news. Would it be better to tell the worst at the onset of the discussion or gradually build up to the worst? It would seem that preparation and an empathetic leading up to the bad news is an appropriate technique. (See the professional advice below). However, I would like to first present two humorous versions of telling worst news at the end. You may have already heard this story.

A man returning home after a few months away is met by his servant who tells him his dog died from eating burnt horseflesh after the barn burned down from a spark blown from the fire that consumed his house. The house fire started from candles placed around the coffin of his mother-in-law who died after learning that her daughter ran off with the hired man. "Other than that," the servant said, "there's no news."


Here is a more ancient expression of the same story from The Project Gutenberg EBook of McGuffey's Fifth Eclectic Reader
by William Holmes McGuffey


HOW TO TELL BAD NEWS.

Mr. H. and the Steward.

Mr. H. Ha! Steward, how are you, my old boy? How do things go on at home?

Steward. Bad enough, your honor; the magpie's dead.

H. Poor Mag! So he's gone. How came he to die?

S. Overeat himself, sir.

H. Did he? A greedy dog; why, what did he get he liked so well?

S. Horseflesh, sir; he died of eating horseflesh,

H. How came he to get so much horseflesh?

S. All your father's horses, sir.

H. What! are they dead, too?

S. Ay, sir; they died of overwork.

H. And why were they overworked, pray?

S. To carry water, sir.

H. To carry water! and what were they carrying water for?

S. Sure, sir, to put out the fire.

H. Fire! what fire?

S. O, sir, your father's house is burned to the ground.

H. My father's house burned down! and how came it set on fire?

S. I think, sir, it must have been the torches.

H. Torches! what torches?

S. At your mother's funeral.

H. My mother dead!

S. Ah, poor lady! she never looked up, after it.

H. After what?

S. The loss of your father.

H. My father gone, too?

S. Yes, poor gentleman! he took to his bed as soon as he heard of it.

H. Heard of what?

S. The bad news, sir, and please your honor.

H. What! more miseries! more bad news!

S. Yes, sir; your bank has failed, and your credit is lost, and you are
not worth a shilling in the world. I made bold, sir, to wait on you about
it, for I thought you would like to hear the news.


I found the following good example, as a teaching tool for medical students, interns and residents (and, of course, to practicing physicians who never learned how to do it) inWeissman, D. Fast Fact and Concepts #11: Delivering Bad News, Part I and Part II-- Talking to Patients and Precepting Trainees. June, 2000. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Case Scenario: You are caring for a previously healthy 52 y/o man with a new problem of abdominal pain. After conservative treatments fail, a diagnostic abdominal CT scan is done showing a focal mass with ulceration in the body of the stomach and numerous (more than 10) densities in the liver compatible with liver metastases. The radiologist feels that the findings are absolutely typical of metastatic stomach cancer. [How do you prepare and then deliver the bad news to the patient?]


Preparing to Deliver the Bad News:

1. Create an appropriate physical setting: A quiet, comfortable room, turn off beeper, check personal appearance, have participants, including yourself, sitting down.

2. Determine who should be present? Ask the patient whom they want to participate--clarify relationships to patient. Decide if you want others present (e.g. nurse, consultant, chaplain, social worker) and obtain patient/family permission.

3. Think through your goals for the meeting as well as possible goals of the patient.

4. Make sure you know basic information about the patient's disease, prognosis, treatment options.

5. Special circumstances: Patient not competent (developmentally delayed, dementia, etc.) Make sure legal decision-maker is present.

6. Special circumstances: Patient doesn't speak English. Obtain a skilled medical interpreter if the patient or family do not speak English. Use ATT translation service or other phone service is necessary.

Delivering the Bad News

1. Determine what the patient & family knows; make no assumptions. Examples: "What is your understanding of your present condition?" "What have the doctors told you?"
2. Before presenting bad news, consider providing a brief overview of the patient's course so that every one has a common source of information.
3. Speak slowly, deliberately and clearly. Provide information in small chunks. Check reception frequently
4. Give fair warning -- "I am afraid I have some bad news" then pause for a moment.
5. Present bad news in a succinct and direct manner. Be prepared to repeat information and present additional information in response to patient and family needs.
6. Sit quietly. Allow the news to sink in. Wait for the patient to respond.
7. Listen carefully and acknowledge patient's and family's emotions, for example by reflecting both the meaning and emotion of their response.
8. Normalize and validate emotional responses: feeling numb, angry, sad, and fearful.
9. Give an early opportunity for questions, comments
10. Present information at the patient's or family's pace; do not overwhelm with detail. The discussion is like pealing an onion. Provide an initial overview. Assess understanding. Answer questions. Provide the next level of detail or repeat more general information depending upon the patient's and family's needs.
11. Assess thoughts of self-harm
12. Agree on a specific follow-up plan ("I will return later today, write down any questions"). Make sure this plan meets the patient's needs. Involve other team members in follow-up.

Just yesterday, my medical student was in the hospital room with a patient. The attending surgeon along with a troop of residents and interns came into the room. The surgeon then without any further preparation and without any attempt at privacy or compassion told the patient of the results of the surgery—the finding of a cancerous liver, a diagnosis the patient had not previously known. My student was shocked by the attending physician’s behavior and provided me with a great teaching moment for our medical school group. Yes, even “grown” physicians need to learn the ethical and compassionate way to do it. ..Maurice.