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Giving bad news to patients: How to do it better

Sarah Zarbock, PA-C

Sarah Zarbock, PA-C, is the editor in chief of JAAPA.

His 6 ft, 2 in height easily collapsed into the chair he had set by the patient’s bedside. He crossed his long legs, rested his hands on his knees, and waited expectantly, as if he had all the time in the world. In fact, he was already half an hour late to see his office patients.

After exchanging some pleasantries with his patient, he said, “I’m afraid the news is not good. The report is back and it’s not what we had hoped for.” Helen, a 74-year-old woman with metastatic colon cancer, was now hospitalized with what probably was an evolving bowel obstruction. After two surgeries and several rounds of chemotherapy and radiation therapy, Helen had run out of treatment options. “I wish the news was different,” he paused. “So I’d like to discuss with you what you would like to have happen.” He then sat quietly, indicating that he was allowing time for the moment to settle over them.

Breaking bad news is one of the most difficult tasks health care providers face. Although medical education is changing, most medical schools provide little focused training on how to accomplish this difficult but very common task.¹ We must find our own way to have these discussions, a way that feels authentic to us and that benefits patients. One way to learn is to watch how it is done by others, listening to examples that help us develop our own dialogue. Although the conversation between Helen and my supervising physician occurred more than 25 years ago, I recall listening closely to his words and have subsequently incorporated some of them into my own difficult discussions.

In addition to listening to other clinicians, we can consider other helpful guidelines and “scripts.” Some examples: “I wish I had better news” (as opposed to “I’m sorry, I have bad news”), “I admire your courage,” “I will be here for you,” and “What gives you hope and strength?” Unhelpful statements include “It could be worse,” “We all die,” “I understand how you feel,” and “Nothing more can be done.”²

Similar lessons can be learned from a study of the medical humanities, an interdisciplinary field of medicine that includes the arts, social sciences, and humanities and their application to medical education and practice. Attention to literature and the arts helps to develop and nurture skills of observation, analysis, empathy, and self-reflection—skills that are essential for humane medical care.³

For instance, viewing “bad news scenes” from films can visually demonstrate the variety of ways this information is delivered. The 1993 film My Life demonstrates the delivery of a terminal prognosis from both the patient’s and physician’s points of view. In My Life Without Me, the doctor clearly suffers and expresses his feelings of helplessness as he tells a young woman she has advanced ovarian cancer. In Wit, a literature professor is told she has advanced ovarian cancer by an oncologist who provides too much information at once, fails to pick up on nonverbal language, and uses medical jargon. Even Charlotte’s Web has a message to tell as it shows how Charlotte’s straightforward attitude about her approaching death is an example of one way to talk about death with children.

PAs can learn more about this topic by attending Breaking Bad News: A CME Session in the Medical Humanities at the AAPA’s 36th annual conference in San Antonio. Presented by Tanya Gregory, PhD, JAAPA’s editor, and Noel Genova, PA-C, a former member of the JAAPA editorial advisory board, this JAAPA-sponsored lecture with discussion session is designed to allow participants to reflect on their own experiences breaking or receiving bad news, as well as to gain insight into patients’ experiences. The lecture component will include a review of the medical literature regarding breaking bad news and will elucidate points raised by Joan Didion in her book The Year of Magical Thinking, a reflection on the death of her husband of 40 years and a nonfiction account of her encounters with the medical system in 2004. Attendees will also write briefly about an instance of breaking bad news from their own experiences and will share and discuss the experience with other attendees. For more information on this session, which is scheduled for Monday, May 26, 8 to 10:45 AM please see the course description posted on the JAAPA Web site at www.jaapa.com/ issues/j20080101/pdfs/ann_breaking.pdf.

In Pauline Chen’s excellent book Final Exam: A Surgeon’s Reflections on Mortality, she comments on her own conflict between being emotionally disengaged from but wanting to be more empathic and truthful to her patients during their end-of-life care. In the midst of her own struggle, she applauds the wisdom of one colleague who comments about what he believes is the most important thing to say to patients when giving them bad news: “I understand that this illness is happening to you; but we will face it together.”⁴ JAAPA

REFERENCES

	1.	Vandekieft GK. Breaking bad news. Am Fam Physician. 2001;64(12):1975-1978.
	2.	Mueller PS. Breaking bad news to patients [editorial]. Postgraduate Medicine. 2002;112(3). http://www.postgradmed.com/issues/2002/09_02/editorial_sep.shtml. Accessed March 20, 2008.
	3.	Mission statement. New York University School of Medicine Medical Humanities Web site. http://medhum.med.nyu.edu/. Accessed March 20, 2008.
	4.	Chen P. Final Exam: A Surgeon’s Reflections on Mortality. New York, NY: Alfred A. Knopf; 2007.