Telling Patients Bad News Takes Practice, Skill, and Compassion

TAMPA – Sharing bad news with patients might not be easy, but it’s a skill physicians can learn and as important as knowing how to ready an EKG or an x-ray, James A. Avery, MD, CMD, 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 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, for example.

"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.

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

• Is there anyone else you want to have in the conversation?
• How do you understand what has happened to you medically?
• What have doctors told you about this illness?
• 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. She had guilt 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 [chronic obstructive pulmonary disease] 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 they received 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, he said.

Allow for silence. Let the message to 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."

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."

"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 long and strong relationship with a patient can be especially poor at prognostication, he said.

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.

If you still do not feel comfortable giving a 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.

If your attitude is right and you’re speaking with a compassionate tone, what else should you keep in mind when giving a patient bad news?

Watch your body language, because about 90% of communication is nonverbal, Dr. Avery said. Make eye contact, for example.

Do not sound matter of fact. "Patients will say the doctor appears bored," Dr. Avery explained. At the same time, avoid rambling, he advised. A good way to do this is intentionally pause on a frequent basis. Develop a technique to slow yourself down. Dr. Avery said he silently counts backward from 10 to slow himself down, for example.

Provide information in small chunks. This is better than "the information dump," which is a tendency to disclose every detail to a patient when initial bad news is shared.

"I tell the patient she can raise her hand and stop me if it’s too much information at any point," he said.

Never say, ‘There is nothing more I can do for you," Dr. Avery advised. He said he often tells patients that there is nothing more he can do for their dementia or their cancer, "but there is a lot I can do for you as a person. ... Otherwise, you are referring to them as a lung cancer, and you’ve reduced them to an organ with a disease."

You also can admit the limitations of medicine, Dr. Avery said. "You can say, for example, ‘I wish we had more effective therapy for your condition,’ or ‘I wish I had a magic pill or magic wand I could use it to take away your cancer.’ "

Dr. Avery said that he had no relevant financial conflict of interest.

TAMPA – Sharing bad news with patients might not be easy, but it’s a skill physicians can learn and as important as knowing how to ready an EKG or an x-ray, James A. Avery, MD, CMD, 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 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, for example.

"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.

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

• Is there anyone else you want to have in the conversation?
• How do you understand what has happened to you medically?
• What have doctors told you about this illness?
• 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. She had guilt 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 [chronic obstructive pulmonary disease] 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 they received 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, he said.

Allow for silence. Let the message to 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."

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."

"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 long and strong relationship with a patient can be especially poor at prognostication, he said.

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.

If you still do not feel comfortable giving a 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.

If your attitude is right and you’re speaking with a compassionate tone, what else should you keep in mind when giving a patient bad news?

Watch your body language, because about 90% of communication is nonverbal, Dr. Avery said. Make eye contact, for example.

Do not sound matter of fact. "Patients will say the doctor appears bored," Dr. Avery explained. At the same time, avoid rambling, he advised. A good way to do this is intentionally pause on a frequent basis. Develop a technique to slow yourself down. Dr. Avery said he silently counts backward from 10 to slow himself down, for example.

Provide information in small chunks. This is better than "the information dump," which is a tendency to disclose every detail to a patient when initial bad news is shared.

"I tell the patient she can raise her hand and stop me if it’s too much information at any point," he said.

Never say, ‘There is nothing more I can do for you," Dr. Avery advised. He said he often tells patients that there is nothing more he can do for their dementia or their cancer, "but there is a lot I can do for you as a person. ... Otherwise, you are referring to them as a lung cancer, and you’ve reduced them to an organ with a disease."

You also can admit the limitations of medicine, Dr. Avery said. "You can say, for example, ‘I wish we had more effective therapy for your condition,’ or ‘I wish I had a magic pill or magic wand I could use it to take away your cancer.’ "

Dr. Avery said that he had no relevant financial conflict of interest.

TAMPA – Sharing bad news with patients might not be easy, but it’s a skill physicians can learn and as important as knowing how to ready an EKG or an x-ray, James A. Avery, MD, CMD, 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 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, for example.

"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.

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

• Is there anyone else you want to have in the conversation?
• How do you understand what has happened to you medically?
• What have doctors told you about this illness?
• 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. She had guilt 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 [chronic obstructive pulmonary disease] 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 they received 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, he said.

Allow for silence. Let the message to 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."

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."

"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 long and strong relationship with a patient can be especially poor at prognostication, he said.

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.

If you still do not feel comfortable giving a 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.

If your attitude is right and you’re speaking with a compassionate tone, what else should you keep in mind when giving a patient bad news?

Watch your body language, because about 90% of communication is nonverbal, Dr. Avery said. Make eye contact, for example.

Do not sound matter of fact. "Patients will say the doctor appears bored," Dr. Avery explained. At the same time, avoid rambling, he advised. A good way to do this is intentionally pause on a frequent basis. Develop a technique to slow yourself down. Dr. Avery said he silently counts backward from 10 to slow himself down, for example.

Provide information in small chunks. This is better than "the information dump," which is a tendency to disclose every detail to a patient when initial bad news is shared.

"I tell the patient she can raise her hand and stop me if it’s too much information at any point," he said.

Never say, ‘There is nothing more I can do for you," Dr. Avery advised. He said he often tells patients that there is nothing more he can do for their dementia or their cancer, "but there is a lot I can do for you as a person. ... Otherwise, you are referring to them as a lung cancer, and you’ve reduced them to an organ with a disease."

You also can admit the limitations of medicine, Dr. Avery said. "You can say, for example, ‘I wish we had more effective therapy for your condition,’ or ‘I wish I had a magic pill or magic wand I could use it to take away your cancer.’ "

Dr. Avery said that he had no relevant financial conflict of interest.