Giving Bad News Takes Practice, Skill, Compassion

TAMPA – Sharing bad news with patients might not be easy, but it’s a skill physicians can learn and is as im­portant as knowing how to ready an EKG or an x-ray, James A. Avery, M.D., said. “What I am proposing is that giving bad news well is a fundamental long-term care physician skill, and competence in this area is critical,” Dr. Avery said at this year’s AMDA – Dedicated to Long Term Care Medicine annual meeting.

“Giving bad news … takes desire, courage, and prac­tice,” said Dr. Avery. “Patients deserve to get bad news delivered with compassion, hope, and integrity.”

Plan ahead for the conversation; start with what the patient knows and wants to know; and develop a com­passionate tone, said Dr. Avery, chief medical officer at Golden Living in Washington, a corporation that fo­cuses on skilled nursing, assisted living, and rehabilita­tion therapy. Also, always provide an appropriate prognosis. “It’s your obligation to bring this up. Patients and families may be afraid to ask.”

What can happen if the conversation is not done cor­rectly? “If bad news is given poorly, it can rob hope and create distress, confusion, and anxiety. It can weaken the patient’s faith and set off a chain of events that adversely affects the survivors for years,” said Dr. Avery.

“I was particularly bad at giving bad news at first,” he said. A pulmonologist by training, he also worked for years in hospice care in both Florida and New York. He spoke with patients who transitioned to hospice from Memorial Sloan-Kettering Cancer Center, New York, for example.

<[stk -1]>“I learned quickly that if I was going to give bad news, not to schedule the patient for midmorning on a Mon­day. It is too chaotic,” Dr. Avery said. Schedule the pa­tient for the first appointment after lunch or at the end of the day. Allow sufficient time and create a comfort­able, private place with tissues available, he added.<[etk]>

Next, determine where each patient is in terms of un­derstanding his or her illness. “Explore and ask,” Dr. Av­ery said. Good questions include:

<[stk -3]>P Is there anyone you want with you in the conversation? <[etk]>

P How do you understand what has happened to you medically?

P What have doctors told you about this illness?

P What do you think caused this illness?

“I cannot tell you how many patients with colon can­cer thought they had it because they took too many antacids,” Dr. Avery said. “Also, I had one woman with breast cancer who responded ‘Burger King.’ She had read an article that fatty foods caused breast cancer and felt guilty that she was leaving her family because she ate burgers instead of salads.”

Also, determine how much the patient wants to know. “About 90% of patients want full information [about their condition], but everyone wants to know everything about treatment.” Physicians also can be in­strumental in allaying end-of-life fears, Dr. Avery said. Regardless of illness, most patients think some symp­tom is going to get worse and worse and crescendo in pain before they die. “How do people with COPD die? Yes, the symptoms get worse, but with COPD, they get COPD narcosis, get sleepy, and drift away.”

Intentionally develop and use a compassionate tone,
Dr. Avery said. This is important because patients sur­veyed after receiving bad news said the attitude of the person who spoke with them was the most important factor. The clarity of the message and privacy were also important, but they ranked far behind clinician attitude.

Allow for silence. Let the message sink in. “Give the patient plenty of time to react, respond, and ask ques­tions.” Also allow tears – “That can be a real problem for a lot of doctors.”

<[stk -1]>A challenge for physicians is to be empathetic with­out breaking down completely, Dr. Avery said. When working in hospice care in New York, he frequently spent the day traveling by subway to clients’ residences. “Am I going to travel around weeping? No. You have to somehow try to meet where they are, but you cannot go there completely. It would be self-destructive.”<[etk]>

“One reason physicians think they do not give bad news well is they fear their own response; that they will break down,” Dr. Avery said. Try to determine the pa­tient’s attitude and reflect it back to them. “This is what you do when things get emotional. And they will cor­rect you if you’re wrong. If you say ‘You sound angry,’ they might say ‘No, I’m upset.’ ”

Another important thing to ask patients is, “Have the doctors told you how long you have?” An accurate prog­nosis will help patients and family prepare, Dr. Avery said. “You have to tell them. If you don’t, they will seek a second opinion and/or leave the long-term care set­ting, because no one has told them.” Less-experienced doctors and doctors who have had a long and strong relationship with a patient can be especially poor at prognostication, he said.

<[stk -1]>Be completely honest and avoid stating a precise amount of time, such as “3 months.” “I say, ‘It could be weeks instead of months,’ or ‘It could be months instead of years.’ If they ask for a more precise prognosis, tell them it’s difficult to say, because it is,” Dr. Avery said. <[etk]>

I have checked the following facts in my story: (Please initial each.)

If you still do not feel comfortable giving the patient bad news, refer the patient to someone who does.

“Call in hospice, call in palliative care. If you cannot give that bad news, you are obligated to do this,” Dr. Avery said.

TAMPA – Sharing bad news with patients might not be easy, but it’s a skill physicians can learn and is as im­portant as knowing how to ready an EKG or an x-ray, James A. Avery, M.D., said. “What I am proposing is that giving bad news well is a fundamental long-term care physician skill, and competence in this area is critical,” Dr. Avery said at this year’s AMDA – Dedicated to Long Term Care Medicine annual meeting.

“Giving bad news … takes desire, courage, and prac­tice,” said Dr. Avery. “Patients deserve to get bad news delivered with compassion, hope, and integrity.”

Plan ahead for the conversation; start with what the patient knows and wants to know; and develop a com­passionate tone, said Dr. Avery, chief medical officer at Golden Living in Washington, a corporation that fo­cuses on skilled nursing, assisted living, and rehabilita­tion therapy. Also, always provide an appropriate prognosis. “It’s your obligation to bring this up. Patients and families may be afraid to ask.”

What can happen if the conversation is not done cor­rectly? “If bad news is given poorly, it can rob hope and create distress, confusion, and anxiety. It can weaken the patient’s faith and set off a chain of events that adversely affects the survivors for years,” said Dr. Avery.

“I was particularly bad at giving bad news at first,” he said. A pulmonologist by training, he also worked for years in hospice care in both Florida and New York. He spoke with patients who transitioned to hospice from Memorial Sloan-Kettering Cancer Center, New York, for example.

<[stk -1]>“I learned quickly that if I was going to give bad news, not to schedule the patient for midmorning on a Mon­day. It is too chaotic,” Dr. Avery said. Schedule the pa­tient for the first appointment after lunch or at the end of the day. Allow sufficient time and create a comfort­able, private place with tissues available, he added.<[etk]>

Next, determine where each patient is in terms of un­derstanding his or her illness. “Explore and ask,” Dr. Av­ery said. Good questions include:

<[stk -3]>P Is there anyone you want with you in the conversation? <[etk]>

P How do you understand what has happened to you medically?

P What have doctors told you about this illness?

P What do you think caused this illness?

“I cannot tell you how many patients with colon can­cer thought they had it because they took too many antacids,” Dr. Avery said. “Also, I had one woman with breast cancer who responded ‘Burger King.’ She had read an article that fatty foods caused breast cancer and felt guilty that she was leaving her family because she ate burgers instead of salads.”

Also, determine how much the patient wants to know. “About 90% of patients want full information [about their condition], but everyone wants to know everything about treatment.” Physicians also can be in­strumental in allaying end-of-life fears, Dr. Avery said. Regardless of illness, most patients think some symp­tom is going to get worse and worse and crescendo in pain before they die. “How do people with COPD die? Yes, the symptoms get worse, but with COPD, they get COPD narcosis, get sleepy, and drift away.”

Intentionally develop and use a compassionate tone,
Dr. Avery said. This is important because patients sur­veyed after receiving bad news said the attitude of the person who spoke with them was the most important factor. The clarity of the message and privacy were also important, but they ranked far behind clinician attitude.

Allow for silence. Let the message sink in. “Give the patient plenty of time to react, respond, and ask ques­tions.” Also allow tears – “That can be a real problem for a lot of doctors.”

<[stk -1]>A challenge for physicians is to be empathetic with­out breaking down completely, Dr. Avery said. When working in hospice care in New York, he frequently spent the day traveling by subway to clients’ residences. “Am I going to travel around weeping? No. You have to somehow try to meet where they are, but you cannot go there completely. It would be self-destructive.”<[etk]>

“One reason physicians think they do not give bad news well is they fear their own response; that they will break down,” Dr. Avery said. Try to determine the pa­tient’s attitude and reflect it back to them. “This is what you do when things get emotional. And they will cor­rect you if you’re wrong. If you say ‘You sound angry,’ they might say ‘No, I’m upset.’ ”

Another important thing to ask patients is, “Have the doctors told you how long you have?” An accurate prog­nosis will help patients and family prepare, Dr. Avery said. “You have to tell them. If you don’t, they will seek a second opinion and/or leave the long-term care set­ting, because no one has told them.” Less-experienced doctors and doctors who have had a long and strong relationship with a patient can be especially poor at prognostication, he said.

<[stk -1]>Be completely honest and avoid stating a precise amount of time, such as “3 months.” “I say, ‘It could be weeks instead of months,’ or ‘It could be months instead of years.’ If they ask for a more precise prognosis, tell them it’s difficult to say, because it is,” Dr. Avery said. <[etk]>

I have checked the following facts in my story: (Please initial each.)

If you still do not feel comfortable giving the patient bad news, refer the patient to someone who does.

“Call in hospice, call in palliative care. If you cannot give that bad news, you are obligated to do this,” Dr. Avery said.

TAMPA – Sharing bad news with patients might not be easy, but it’s a skill physicians can learn and is as im­portant as knowing how to ready an EKG or an x-ray, James A. Avery, M.D., said. “What I am proposing is that giving bad news well is a fundamental long-term care physician skill, and competence in this area is critical,” Dr. Avery said at this year’s AMDA – Dedicated to Long Term Care Medicine annual meeting.

“Giving bad news … takes desire, courage, and prac­tice,” said Dr. Avery. “Patients deserve to get bad news delivered with compassion, hope, and integrity.”

Plan ahead for the conversation; start with what the patient knows and wants to know; and develop a com­passionate tone, said Dr. Avery, chief medical officer at Golden Living in Washington, a corporation that fo­cuses on skilled nursing, assisted living, and rehabilita­tion therapy. Also, always provide an appropriate prognosis. “It’s your obligation to bring this up. Patients and families may be afraid to ask.”

What can happen if the conversation is not done cor­rectly? “If bad news is given poorly, it can rob hope and create distress, confusion, and anxiety. It can weaken the patient’s faith and set off a chain of events that adversely affects the survivors for years,” said Dr. Avery.

“I was particularly bad at giving bad news at first,” he said. A pulmonologist by training, he also worked for years in hospice care in both Florida and New York. He spoke with patients who transitioned to hospice from Memorial Sloan-Kettering Cancer Center, New York, for example.

<[stk -1]>“I learned quickly that if I was going to give bad news, not to schedule the patient for midmorning on a Mon­day. It is too chaotic,” Dr. Avery said. Schedule the pa­tient for the first appointment after lunch or at the end of the day. Allow sufficient time and create a comfort­able, private place with tissues available, he added.<[etk]>

Next, determine where each patient is in terms of un­derstanding his or her illness. “Explore and ask,” Dr. Av­ery said. Good questions include:

<[stk -3]>P Is there anyone you want with you in the conversation? <[etk]>

P How do you understand what has happened to you medically?

P What have doctors told you about this illness?

P What do you think caused this illness?

“I cannot tell you how many patients with colon can­cer thought they had it because they took too many antacids,” Dr. Avery said. “Also, I had one woman with breast cancer who responded ‘Burger King.’ She had read an article that fatty foods caused breast cancer and felt guilty that she was leaving her family because she ate burgers instead of salads.”

Also, determine how much the patient wants to know. “About 90% of patients want full information [about their condition], but everyone wants to know everything about treatment.” Physicians also can be in­strumental in allaying end-of-life fears, Dr. Avery said. Regardless of illness, most patients think some symp­tom is going to get worse and worse and crescendo in pain before they die. “How do people with COPD die? Yes, the symptoms get worse, but with COPD, they get COPD narcosis, get sleepy, and drift away.”

Intentionally develop and use a compassionate tone,
Dr. Avery said. This is important because patients sur­veyed after receiving bad news said the attitude of the person who spoke with them was the most important factor. The clarity of the message and privacy were also important, but they ranked far behind clinician attitude.

Allow for silence. Let the message sink in. “Give the patient plenty of time to react, respond, and ask ques­tions.” Also allow tears – “That can be a real problem for a lot of doctors.”

<[stk -1]>A challenge for physicians is to be empathetic with­out breaking down completely, Dr. Avery said. When working in hospice care in New York, he frequently spent the day traveling by subway to clients’ residences. “Am I going to travel around weeping? No. You have to somehow try to meet where they are, but you cannot go there completely. It would be self-destructive.”<[etk]>

“One reason physicians think they do not give bad news well is they fear their own response; that they will break down,” Dr. Avery said. Try to determine the pa­tient’s attitude and reflect it back to them. “This is what you do when things get emotional. And they will cor­rect you if you’re wrong. If you say ‘You sound angry,’ they might say ‘No, I’m upset.’ ”

Another important thing to ask patients is, “Have the doctors told you how long you have?” An accurate prog­nosis will help patients and family prepare, Dr. Avery said. “You have to tell them. If you don’t, they will seek a second opinion and/or leave the long-term care set­ting, because no one has told them.” Less-experienced doctors and doctors who have had a long and strong relationship with a patient can be especially poor at prognostication, he said.

<[stk -1]>Be completely honest and avoid stating a precise amount of time, such as “3 months.” “I say, ‘It could be weeks instead of months,’ or ‘It could be months instead of years.’ If they ask for a more precise prognosis, tell them it’s difficult to say, because it is,” Dr. Avery said. <[etk]>

I have checked the following facts in my story: (Please initial each.)

If you still do not feel comfortable giving the patient bad news, refer the patient to someone who does.

“Call in hospice, call in palliative care. If you cannot give that bad news, you are obligated to do this,” Dr. Avery said.