"A moment please," my mother says to the nurse, pressing a tissue to my face, and I understand that she is the perfect person for this moment, that she is the perfect person to tell someone news so bad that no one else can even form the words. I wonder if she was always this way, or if she learned to be this way when someone told her terrible things.
- "Every Last One" by Anna Quindlen 2010
As a neurologist who specializes in rehabilitation there have been countless times in my career when I have had to deliver terrible news to a patient or family. There was the young man with the incurable brain tumor and the family of the teenager who could not believe that their daughter would never awaken from her coma. I try to think back to the first time that I had to figure out how to phrase the words, comfort the family and "act professional." I really can't remember a specific first encounter, but even worse is the fact that I cannot remember ever being shown or told how to deliver bad news. Imagine that you are the first person to tell a woman that she has breast cancer or a man that he has Parkinson's disease that will change his life forever. But, it isn't just health care providers. Like Mary Beth's mother in the novel, "Every Last One," you may be pulled into this role.
What Is Bad News?
Early in my career I remember being told that, "Life is full of bad news." The person's point was not to win the "cynic of the year award", but to make me aware that it is all about the perspective of the particular individual. While your initial thought might be that we are talking about cancer, bad news comes in many different forms.
We have to understand the other person's perception of the event and how this news will impact them. Stress is very much about dealing with unmet expectations, so first we must understand the other person's expectations. We must anticipate how they will receive the news we are about to deliver.
It is surprising how little attention is paid to this important issue during our medical training. It wasn't that long ago that it was acceptable to conceal the whole truth from a patient and many family members didn't want to "burden" their mother with the truth about her terminal illness. Today, full disclosure is mandatory and the vast majority of people want to know everything. Most of us deal much more effectively with the details of what is known as opposed to the uncertainty of the unknown.
We must learn to avoid the scene that is played out nightly on our television screens. The doctor in green scrubs approaches a family, shakes his head slightly and the family begins to cry and mourn as the young handsome physician retreats behind the swinging doors.
The 6 Step SPIKES Strategy
For the last 20 years, Dr. Robert Buckman, an oncologist at the University of Toronto, has been at the forefront of teaching health care professional how to communicate bad news. His 1992 book, "How to Break Bad News" introduced a 6 Step Protocol for delivering bad news. In 1998 he introduced the S-P-I-K-E-S strategy that supplied an easy way to remember the 6 steps, while a subsequent article in Community Oncology clearly outlined the six steps and strategies. These six steps are useful, not only in a health care setting but, also in such "bad news" situations as having to tell someone they are losing their job, telling a child about an impending divorce or a spouse about the loss of their loved one.
• Setting (S) - I am always amazed and appalled by how many people impersonally convey bad news over the telephone. Always deliver bad news in person and have the individual bring another person with them as an extra set of ears. The setting is important and should be private and as distraction free as possible. Turn off your phone! Don't just jump into the "facts," but start a dialogue with the person. A simple inquiry of, "how are you feeling right now?" can help start the conversation. Listen and don't interrupt, as it sends a clear message that you care about the person's feelings and what is about to take place.
• Perception (P) - It is important to find out how much the person knows and why do they think they are meeting with you? Exploratory questions like, "What have you been told so far?" or "What is your understanding of the situation?" are helpful in determining where to start your explanation.
• Invitation (I) - Although most people want the whole truth and nothing but the truth, it is best to establish this as a fact. Educational levels, along with medical sophistication vary greatly and different people will want different amounts of detail. Gauge how much detail this patient or family wants to know.
• Knowledge (K) - Give people a warning of what is to come with opening statements like, "I wish I had better news" or "I am sorry to have to tell you this." It gives the person a chance to prepare themselves. Deliver the information in small digestible bites, as people will shut down and not remember much else after the initial statement of bad news. Make sure they are ready to move on to the next bit of information, for the more information you give out, the less they will recall. If the person starts to cry, take a break and be sure that they are once again ready to move forward. You don't need to race for a box of tissues, but be prepared to react calmly to what may be a very emotional response.
• Empathy (E) - Let the person know that you understand that this is a difficult time and situation for them. It is demeaning to say, "I know how you feel," unless you really do. I often say, "I have never had to walk in your shoes and I hope that I never will, but I can help you through this." It is helpful to ask someone, "What are you feeling?" and to empathize with them by saying, "This must be very distressing to you."
• Strategy and Summarize (S) - Briefly summarize the conversation that just took place and articulate a plan for the future. Make sure that they know that you are available and how to get hold of you. It can be particularly helpful to have the person tell you in their own words what you just told them, explaining that, "I want to make sure I did a good job explaining this to you."
You may not get it right every time, but hopefully you will get it wrong less often. Chances are that most people have been in this situation, so this is a good opportunity for you to tell us your personal experiences in either receiving or having to deliver bad news.
Follow Richard C. Senelick, M.D. on Twitter: www.twitter.com/RichardSenelick
Thomas Goetz: Doctor Patient Relationship: 5 Ways Doctors Can Really Help Patients
Breaking Bad News | Doctor | Patient UK
Zondervan - When Your Doctor Has Bad News - Al B. Weir
BBC - Health: Doctor-patient relationship
Doctor-patient relationship - Wikipedia, the free encyclopedia
Doc-Patient Relationship May Be Key to Quality - US News and World ...
Well - Contentious Relationships Between Doctors and Patients ...
Now they call a disease like that palliative..but it used to be called terminal cancer. And I think there may not be clear guidelines about what palliative care means...but for me it has been a descent into Hell.
and it looks like they are applying general statistics to an individual and not considering his condition. Only 20% live one year...and he has been in that 20%. I think if they had gone after the cancer more aggressively it would have been better..but they do not listen and follow their own ideas about what should be done, by using statistical modals that give the number of months in extended life with a drug or a protocol. He has had almost no side effects from the chemo...but the cancer is progressing...
Something is wrong with what they are doing...They leave very little room for the patient to give an opinion...and no room at all for a patient not being within their statistical model.
How long have they been using the idea of palliative care? Its new to me...What is also kind of freaky is the way they recite some memorized sentences about what palliative care is...
Of course, doctors are only human as well. I've had two that are good doctors that had to give me the bad news that I had progressed Lyme Disease. They were as horrified as I was (both are fellow hikers). Instead of doing most of the above, we just sat quietly in the room together for a bit - that sense of their empathy was helpful even if words weren't really exchanged. What helped most was knowing the line of communication was open past that appointment - I could call if I needed anything, another appointment, or even just to complain about symptoms while I was being treated with antibiotics.
I'd like to mention one thing, however. Is it possible that doctors become inured to suffering because they see so very much of it? Do they lose a part of their humanity along the way? Police will tell you they assume everyone is guilty because they come in contact with so many who are. They don't start out that way. They just get that way over time. Is it the same with doctors?
But other than that; thank you.
If they don't want to be bashed, how about doing BETTER at their profession? You don't automatically get a hug and a kiss for being bad at your job no matter if you are a doctor.
Reminds me of the high schooler who goes into the classroom and chokes the teacher stating "you will give me the A..."
While I respect your position in life, I don't respect your sense of priority. It seems adrift for a physican either young or old. As for the bashing, I agree, don't generalize. That said, ask me how many really good doctors I've had in my 6 decades of living. Some shouldn't be seeing patients at all and a handful were incredibly good. All were paid the same whether good or not. And most importantly, even the bad ones thought they were good. I never did categorize them by age. I have no clue where you get such a bias.
While I admire your honesty, I find your integrity to be in serious question. If you believe that compassion, kindness and empathy for a patient under YOUR care does not come from your heart, but is dictated by the financial renumeration of a billing code, you are the embodiment of what is wrong with the medical profession today.
Please, for all of us, hang up your coat and just get out of the profession. You do not need to wait the 20 years to bear the accolade of sub-par, you are already there.
My compassion, kindness, and empathy keep me in this profession. Bad doctors should be out..end of story. Every American deserves excellent health care. I speak to my patients and their families at all hours. Everyone has access to my private cell phone. But I think we need a national health system so everyone can get great health care...and MDs don't spend more time fighting with insurance companues than they do speaking with patient. I will never "hang up my coat" because medicine is my passion and my calling. As a young doctor, I simply see quality getting worse and worse as a result of our current system.
I only had the best intentions to be truthful. Americans NEED to know what the systemic problems are. I apologize if you took this the wrong way. If you saw me as a patient, I think you would never doubt my motivations....nor my skills. I just feel the public is kept intentionally in the dark by gov. and insurance companies. As I miss another one of my kids' soccer games to await a patient phone call, I cannot help but be hurt by the irony of your commments. Truce?
I guess it's lucky she didn't go into pediatrics.