Delivering Grave News with Empathy and Honesty

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The patient in the coronary care unit anxiously awaits his physician. On entering the room, the physician bluntly declares, “I have bad news. You have what we call a widow maker.”

Relaying life-changing news to patients is “one of the most daunting tasks in becoming a physician,” said Thomas Cox, PsyD, division director of research and education at Baylor Scott and White, a health care system that includes Baylor University Medical Center (BUMC). “It requires training to make it more humanistic and less stressful for everyone involved.”

When Cox co-authored a survey of surgery residents and faculty at BUMC, he discovered that 91 percent of respondents thought delivering grave news was an important skill, but only 40 percent felt adequately trained to do so. Baylor has since launched a pilot program to introduce this training to students.

Thursday, September 08, 2016

Teaching Residents How to Communicate Difficult News

A survey two years ago at Baylor College of Medicine revealed that surgical residents and faculty felt they lacked the training to deliver distressing news to patients. To address this deficit, Cox and his team developed a pilot program that includes a one-hour lecture followed by case studies and simulations with standardized patients. “We’ve seen a great improvement over the year,” Cox reported.
Physicians in the program are taught to:

  • Arrange adequate time and do advance preparation about what to say. 
  • Turn off cell phones and begin with, “I’m sorry. I have some news.” Avoid saying “bad” news.  Ask, “What do you understand about your condition...? Would you like the full details of your illness?” These questions invite patients to enter into a conversation and reveal the level of their understanding.
  • Focus first on the diagnosis, not on everything that will follow. Refrain from using medical jargon.
  • Give information in small chunks. Don’t dump a lot of information at once.
  • Encourage questions. Don’t assume patients understand their illness.
  • Expect patients to have a range of emotions. Give them time to react with tears, disbelief, denial, or silence. Pass the tissues. Be empathic.
  • Ask patients to paraphrase what has been said to make sure they understand.
  • Debrief with an attending or other colleague to express any sadness or feelings of guilt after delivering the news.
“Medical students and residents will be [delivering bad news] thousands of times in their careers, and they’re not going to learn it effectively by the seat of their pants,” said Walter F. Baile, MD, professor of psychiatry and behavioral science at the University of Texas MD Anderson Cancer Center and director of the Interpersonal Communication and Relationship Enhancement program in the Department of Faculty Development. “They need opportunities to practice these skills with standardized patients. And skills need to be reinforced during residency and thereafter.”

Baile and others developed SPIKES, a protocol for relaying troubling news. The plan guides clinicians in how to gather information from patients to gauge their readiness to hear the news; convey information appropriately; provide empathy and support; and engage patients in planning for the future.

Bluntly telling patients about a grim diagnosis or prognosis can be frightening and traumatic, Baile explained. “Starting with ‘I’m sorry I have some serious news’ gives patients space to buckle their seatbelts for what is coming. There’s a difference between being direct and making patients feel hopeless,” he added. “You can give them hope if a treatment exists; if not, telling them they’ll be supported and given the best care can be reassuring. Balancing honesty and hope is a challenging but important skill to be learned.”

“One of the hardest things for doctors”

Delivering bad news “is one of the hardest things for doctors because it can make them feel helpless but is also sad for the patient,” Baile observed. At MD Anderson, giving serious news is taught using “sociodramas” in which students assume the patient’s role.  Baile explained that it is a powerful learning experience and opens the door to effective communication. Other schools use actors to role-play so students get practice in conveying difficult news compassionately and without using alarming terms.

James A. Tulsky, MD, chair of the Department of Psychosocial Oncology and Palliative Care at Dana-Farber Cancer Institute and professor of medicine at Harvard Medical School, advises trainees to avoid the phrase “bad news” altogether and refer to the news as “serious.”

From his teaching experience, Tulsky said that students need to acquire a “cognitive frame” or “talking map” to think through the arc of a conversation—“how to get from here to there.” He also noted that students need a non-threatening environment to practice these communication skills. If students feel they’re being observed or graded, they may be even more uncomfortable. Better, he suggested, for them to practice first with other students and later with standardized patients.

“There’s a difference between being direct and making patients feel hopeless.”

Walter F. Baile, MD, University of Texas MD Anderson Cancer Center

“[Physicians] also need space to manage patients’ emotions while showing empathy,” Tulsky noted. “But they shouldn’t back-pedal by saying something like, ‘It’s not so bad’ or ‘This is the good kind of cancer.’ And they shouldn’t expect to fix it. Their goal should be to make the patient feel safe and cared for. They could say, ‘I know this is scary, and I’ll be there for you.’

 John Prescott, MD, AAMC chief academic officer and a former emergency medicine physician, notes that physicians in emergency departments have an additional challenge. “Emergency physicians seldom have an established relationship with the patient they are treating and decisions need to be made quickly.”

To establish rapport, said Prescott, “I introduced myself, made eye contact with all of the family members and sat down to be at the same level as the patient or family member. I often made sure that I ‘looked the part’ by wearing my white coat and when appropriate, would hold their hands.” After delivering stressful news, Prescott said he would leave the room to give the patient and family members privacy and time to think about what was said. He would then return a few minutes later to answer additional questions.

On hearing negative news, patients may initially worry about whether or how to tell their families. In those situations, Baile suggested that doctors explore the patients’ concerns and ask if they’d like to bring someone along to the next appointment.

If the patient is a child or teenager, delivering a somber diagnosis can be especially challenging. “Withholding news from children only makes them more anxious because even young children know something is wrong,” Baile said. “Everyone is different. The news should be given in a patient-centered way. Doctors should determine first how much the patient knows and then tailor information to the individual’s age and comprehension level.”

As more and more hospitals move to telemedicine, how do physicians proceed with delivering serious news? “Ideally it’s better to deliver it in person, say by bringing someone back into the clinic,” Tulsky said. “Over the phone or on a video screen, you can lose the non-verbal responses, and it’s harder to ensure safety over the phone. But if it has to be done that way, you have to pay much more attention to your words.”