August 24, 1999

PERSONAL HEALTH

Bad News, Well Delivered: A Prescription for Doctors

Breathing difficulties prompted Frank to return to the hospital days before he was to receive his next chemotherapy treatment for lung cancer. When Frank asked if he'd be getting his treatment as scheduled, a doctor neither he nor his family had ever seen before replied bluntly: "We can't give you another treatment. It would kill you."

To Frank, who knew his life depended on the drugs, those 10 words were a death sentence, delivered in the cruelest possible fashion. Frank's shaken family members were left on their own to try in vain to rekindle some slim hope for his survival.

It was not that the doctor meant to be cruel. It is that few doctors are trained to deliver bad news, and many -- in haste, anxiety, guilt or sheer ignorance of the impact of their words -- say things to patients and families that cause needless emotional pain and may even compromise the effectiveness of treatment.

Physicians often adopt coping strategies to minimize their own discomfort with delivering bad news but fail to realize what is needed to minimize the trauma to patients. If bad news is delivered badly, it can permanently damage the doctor-patient relationship, leading to a loss of confidence in the doctor's recommendations and treatment plan.

People vary greatly in their ability to cope with bad news, whether it involves a diagnosis of a chronic illness, a potentially fatal disease, the realization that the best available treatment isn't working or the unexpected death of a loved one.

To be sure, receiving bad news always causes some level of distress. But researchers say that how the news is delivered influences how well that stress is handled and whether it fosters or impedes a person's ability to cope with the situation.

The harm done can be long lasting, even permanent. In a review of the medical literature on conveying bad news, published in 1996 in The Journal of the American Medical Association, Dr. J. T. Ptacek and Tara L. Eberhardt, psychologists at Bucknell University, stated: "Our conversations with cancer survivors suggest that, even after a relatively lengthy period of time, they are able to recall what made getting the news more or less difficult. Some of these cancer survivors expressed persistent negative feelings about the process. We have also noted some family members continued to harbor intense negative feelings about how the news was conveyed."

Although there have been few scientifically designed studies of the best ways best to convey bad news to patients and families, many expert opinions have been rendered based on the experiences of both medical personnel and patients.

What You Should Expect

Serious matters about your health should be discussed face to face in a quiet, comfortable, private place, not in the hall, on the phone or in the middle of grand rounds with half a dozen strangers listening.

Ideally, a caring relative or friend should be present to provide emotional support and assist in gathering critical information. Too often, after the initial statement of bad news, patients fail to hear most of what else the doctor says and may end up feeling unduly hopeless when in fact the doctor has suggested treatments that are likely to succeed.

Last summer in the journal Behavioral Medicine, Dr. Afaf Girgis and Dr. Rob W. Sanson-Fisher, cancer education researchers in Newcastle, Australia, outlined principles for breaking bad news. Only one person, ideally the primary care physician or senior consultant caring for the patient, should do the job, they insist. The task should not be delegated to a nurse or medical resident.

When imparting bad news, the physician should allow an open-ended amount of time free of interruptions, sit close to the patient at eye level, look directly at the patient and, if appropriate, touch the patient. Dr. Ptacek and Ms. Eberhardt noted that "to hold hands or give a hug can have a strong, positive and lasting effect if done at the right time and with the right patient." Dr. Girgis and Dr. Sanson-Fisher stated that touch could be used "to convey warmth, sympathy, encouragement or reassurance."

Euphemisms like "growth," "tumor" or "cyst" should be avoided when in fact the patient has cancer. Euphemisms lead to misunderstandings and may cause the patient to wonder why such drastic therapy is needed. However, technical jargon also must be avoided. Patients and their families should ask for explanations when they hear something they don't understand.

And, they should be given as much information as needed to understand the condition, its treatment and the likelihood that treatment will cure the illness or control its symptoms.

In one study of cancer patients, the vast majority said they wanted all available information, whether good or bad, about their condition. The diagnosis and prognosis (but without a definite time frame) should be given honestly but not bluntly. A sensitive physician, particularly one who has had a prior relationship with you, will be able to sense just how much information and detail you can handle at one time.

Treatment options and the reasons for more tests should be clearly described along with their likely or possible side effects so that people can make an intelligent choice.

The physician should periodically assess the patient's understanding of the situation.

And, if you're involved, ask whether the discussion can be tape-recorded so that you, your relatives and friends can listen to it again and again, if needed, to gain a more complete understanding of what is happening. The doctor should also arrange to call again the next day or at least provide a phone number and time to call if questions arise later, as they inevitably do.

There should be ample opportunity to vent feelings and to ask questions. The doctor should encourage patients and families to express feelings freely. "Immediate reactions to bad news may include crying, stunned silence, disbelief, anger or acute distress," Dr. Girgis and Dr. Sanson-Fisher wrote. Doctors should let patients know that "it is quite normal to feel this way." And those who think it will be difficult to tell relatives or colleagues about the condition should ask the doctor to assist.

Patients and relatives also should be told about available support services, including support groups for patients and spouses coping with the same disease. If the patient is terminally ill or dies, information about hospice care or bereavement counseling should be provided.

But no matter how grave the situation, a patient should never be told that "nothing more can be done." There is always something the doctor can offer. If there is no treatment that can curb the disease, there is at least treatment to make the patient as comfortable as possible. But the doctor should never suggest that palliative treatment might cure the disease and should make sure the patient understands that.

"Hope should always be conveyed," Dr. Ptacek and Ms. Eberhardt wrote. "The goal of maintaining hope does not mean that physicians should be less than truthful. In the case of imminent death, hope may entail information about the physician's ability to control symptoms and minimize discomfort."

When patients cannot be cured, feelings of guilt and helplessness may prompt the doctor to abandon the patient. An understanding word from the patient's family may help the doctor overcome these feelings and remain a source of comfort and hope. In dealing with bad news, doctors need all the help they can get.


By JANE E. BRODY
Copyright 1999 The New York Times Company
<http://www12.nytimes.com/library/national/science/082499hth-brody.html>

janet paterson
52 now / 41 dx / 37 onset
po box 171, almonte, ontario, canada, K0A 1A0
a new voice: http://www.geocities.com/SoHo/Village/6263/
[log in to unmask]