Communicating Bad News Well

"For doctors, learning what to say when they must deliver bad news can be grueling.

All doctors have these talks from time to time, but cancer doctors face more than their share. According to one estimate, over the course of a career an oncologist will break bad news to patients about 20,000 times, from the first shocking facts of the diagnosis to the news that death is near.

Despite all the practice, it is the rare doctor who is any good at these discussions. And while some medical schools now offer basic communication courses, more sophisticated training for specialists is uncommon. One recent survey found that less than a third of oncology training programs attempted any form of communication training; only about 5 percent of practicing oncologists have had any.

"The general feeling has been that these are not teachable skills - that either you have it or you don't," said Dr. Anthony Back, an oncologist at the Fred Hutchinson Cancer Research Center in Seattle.

Not only do most doctors not have it, Dr. Back said, but those who do generally hone their skills by trial and error, saying all the wrong things until they find the right ones, leaving a trail of tangled miscommunications and alienated patients.

When it comes to saying these words, "I don't think patients realize how worried we are," said Dr. Daniel Carrizosa, one of the students, who is completing his oncology training at the University of North Carolina.

Research shows that he is right. For patients, the flood of emotion that comes with bad news drowns out everything else, especially the reasoned intellectual responses that usually guide human interactions.

Scans have actually shown that patients react to upsetting news first with the primitive limbic lobe of the brain that guides the deepest instincts and emotions.

"If a patient is back in her limbic lobe, she's not going to hear a thing you say," said Dr. Walter Baile, chief of psychiatry at M. D. Anderson Cancer Center in Houston and one of the course preceptors.

As a result, the stilted, jargon-ridden, information-packed sentences in which most doctors encase bad news are pointless. Patients remember nothing about them except the fact that the doctor clearly has not a clue what they are experiencing.

Thus a week long practical role play course in medical communication funded by the National Cancer Institute with actors playing the role of patients. See the NY Times article

"This is so uncomfortable," said Dr. Biren Saraiya, an oncology fellow at the University of Medicine and Dentistry of New Jersey, searching in vain for the right words to tell a jaunty young man that a routine blood test is abnormal and that the cancer the patient thought he had licked might be back.

"He's young, not much older than me," Dr. Saraiya said. "I am afraid for him. But how afraid should I make him?"

His preceptor, Dr. Robert Arnold, an internist and communications expert at the University of Pittsburgh, suggested: "Name your emotions. And then acknowledge he doesn't have to have the same ones."

Sometimes a phrase like "you pay me to do the worrying" will strike the right note of empathy and concern, Dr. Arnold said. Sometimes, though, it will infuriate a patient who hates to be patronized. So find out who the patient is, he said. Be direct. "Say 'Help me understand your story,' or 'Are you the kind of person who likes to know all the details?' Dr. Arnold said. "Figure out what kind of doctor your patient wants you to be."

Over the week, the students learn helpful phrases for all the landmark conversations of bad cancer, from the first intimation that a cure is not possible to the discussions of how and where patients want to live their last weeks.

Saying, "I wish things were different" can let patients and families know that things are going badly, but emphasize that the doctor is on their side, said Dr. James Tulsky, a palliative care expert at Duke. "Hope for the best; prepare for the worst" can be a useful mantra, too.

The doctors learn never to give bad news while standing up, never to do it in a public corridor, always to have a box of Kleenex at hand. They learn not to try to cheer up patients who have every right to be grief-stricken. They learn to address the reasons behind the question, "How long do I have?" rather than just reciting numbers that are invariably inaccurate.

Book recommendation for those journeying with someone who is terminally ill:

Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying by Callanan and Patricia Kelley, Bantam Books, 1992

Guide Review - Book Review: Final Gifts

"At a visit to a patient not so long ago, the patients family told me that he wanted to be dressed in his suit and to pack his suitcase. His family was confused and asked where he thought he was going. He simply said "home". Similar stories are shared in this beautifully written book. The dying can communicate their needs and even convey what they feel if we know how to listen.

Final Gifts: Understanding the Special Awareness, Needs, and Communication of the Dying draws on the authors' 57 years of combined experience caring for the dying -- experience that is priceless for those of us who are facing death for the first time. Poignant stories of real patients and their loved ones paint us a picture of what the dying so desperately want us to know.

The last chapter provides practical uses and tips to applying them in your particular situation. It even includes a section for professional caregivers, and I'm certain I will be applying all of the tips in my practice.

And if your wondering, my patient did go "home" that evening. He died just hours after I left."