OMED 2011: How to break bad news to patients and discuss end of life
Inevitably, every family physician must tell a patient that he or she is dying or has a life-threatening disease.
Although it is not a comfortable conversation to have, an osteopathic physician’s holistic training provides a good foundation for meeting the patient’s needs, said AOA Immediate Past President Karen J. Nichols, DO, during OMED 2011. The panel session on end-of-life care was held Monday in Orlando, Fla., by the American College of Osteopathic Family Physicians.
A physician can find great satisfaction in helping people through such a difficult time, said Dr. Nichols, the dean of the Midwestern University/Chicago College of Osteopathic Medicine (MWU/CCOM) in Downers Grove, Ill.
Dr. Nichols shared a protocol adapted from Robert Buckman, MD, on how to break bad news to patients or their family members, or both:
- Find out how much the patient knows.
- Find out how much the patient wants to know.
- Share the information.
- Respond to patient’s and family’s feelings.
- Plan the follow-up.
Preparation and evaluation
Although it can be tempting to delegate a student or staff member to break the bad news to a patient, Dr. Nichols said, “Don’t delegate. It is not appropriate for anyone other than the physician to have this conversation.”
Before meeting with the patient, the physician should arrange for sufficient, uninterrupted time. Dr. Nichols recommended getting all the medical facts together. “It’s a horrible sinking feeling when you go into the room and realize you don’t have the pathology report,” she said.
It helps to prepare the patient for the news, said another panel member, Joel Policzer, MD, the national medical director for VITAS Innovative Hospital Care in Fort Lauderdale, Fla. “Say ‘We’re going to talk about things that are not pleasant.’ ”
If the patient is unprepared to understand the bad news or wants someone to be there who is not present, Dr. Nichols said to reschedule the meeting. She also believes it is important to ask the patient how much he or she wants to know about the prognosis and to support those preferences. Be aware of cultural, ethnic, religious and socioeconomic factors that may account for people dealing with information differently than expected.
Often, physicians encounter family members who do not want to tell the patient the bad news of a life-limiting illness. Dr. Nichols told the physicians in the audience to ask the family members why they do not want their loved one to know and to address those concerns before encouraging them to be honest with the patient.
Sharing the information
After sharing the news, the physician should stop talking. “Let them react and ask questions,” Dr. Nichols said. “Be prepared for strong emotions. Listen quietly.”
She warned about the implications of saying “I’m sorry,” which can imply wrongdoing.
“One thing I hope you take away is to not say ‘I’m sorry.’ Say ‘I wish,’ as in ‘I wish you didn’t have this problem’ or ‘I wish you didn’t have to go through this.’ ”
Dr. Policzer emphasized not to say “there’s nothing more to do.” He said, “Patients perceive this as abandonment. Also, there’s always something you can do. It may be to help them have better quality of life when longer life is not possible.”
If a patient with a life-limiting illness wants to know life expectancy, avoid precise predictions, such as three months. Instead, say “weeks to months,” Dr. Nichols advised.
Conclude the meeting, she said, by leaving the patient with any needed referrals, sources of support and your contact information.
“Say ‘I’m going to be there [for you],’ ” Dr. Nichols stated.
When language is a barrier, use a skilled medical translator or telephone translation service rather than family. “Family members may not understand how to translate medical concepts,” Dr. Nichols said, “or they may modify the news to protect the patient.”
She added that the physician should speak directly to the patient, not the translator.
An end-of-life discussion is even more challenging when a physician does not know the patient’s family member or does not have a relationship with a new patient, an audience member commented. Nicholas G. Parise, DO, an assistant professor of medicine at MWU/CCOM and a hospice volunteer, said, “You’re not trusted no matter how kind you are.”
Dr. Policzer proposed a way to possibly prevent family members’ anger or blame. He suggested starting the conversation by saying, “I have not had the privilege of knowing your mother until two days ago.”
According to Dr. Policzer, by asking the family members to describe their loved one’s recent condition before then, the physician can help them understand—and hopefully better accept—the patient’s physical deterioration.