Patient communication

How to break bad news to patients: Experts offer best practices

These communication strategies can help you better serve your patients during difficult moments.

After undergoing a routine colonoscopy, the 50-year-old patient learned that his doctor found a tumor. Immediately after delivering the news, the doctor and nurse left the room. Confused by the sudden departure—and the office staff who avoided his gaze—the patient got the impression that the doctor and staff were angry with him.

Health care communications expert Edward Leigh often hears stories like this, illustrating the fact that a physician’s communication style has a drastic effect on the patient experience.

Many physicians haven’t learned the best, most compassionate techniques for telling patients bad news, says Leigh, who directs the Center for Healthcare Communication in Cleveland. They may assume that that particular skill is more necessary if you’re an oncologist.

Yet, physicians in nearly every specialty will frequently find themselves in the position of giving an unpleasant diagnosis or prognosis. Leigh offers specific tips for before, during and after giving bad news.

Before giving the news

    • Take a few minutes to think through what you’re going to say to the patient, Leigh says.
    • Brainstorm additional resources you can offer the patient, such as the website or handout for a support group, a social worker or other support organization. “I’ve interviewed so many patients who said they found these organizations on their own, and they wish they had known about them earlier,” Leigh says.
    • Make sure the appointment is distraction-free by silencing your phone, and make every effort to see the patient in a quiet place.
    • There should be a box of tissues in the room; be prepared to offer them if there are tears.
    • Know that sharing bad news will also be a painful experience, for you, the physician, says Joshua Miller, DO, who leads communication training sessions for physicians at the Cleveland Clinic.

      “Physicians care about their patients,” says Dr. Miller, who is also the vice president of regional medical operations at Cleveland Clinic. “When something bad happens to your patient, it can hit you in many ways. Understanding that will better prepare you for the encounter and the emotions that come with it.”

Breaking the bad news

    • Immediately before sharing the bad news, you’ll want to ask the patient how much they already know. This will help you avoid communication mishaps that can occur in hospitals or scenarios when patients are seeing multiple physicians.

For instance, Leigh recalls a physician he worked with who once told a patient’s husband that her lung cancer had metastasized, only to learn that the patient’s husband wasn’t aware that his wife had been diagnosed with cancer. “He told me it was the biggest mistake of his career,” Leigh says.

    • Provide a “warning shot:” This could be a statement such as, “I’m afraid I have some difficult news,” which helps prepare the patient for what’s to come.
    • Give the news using minimal medical jargon, then empathize. “Deliver an empathetic statement immediately after sharing the news,” Leigh suggests. “That could be, ‘I know this is difficult to hear.’ ‘I know this is upsetting news.’ ”
Joshua Miller, DO

Afterward

    • Allow a moment of silence. Uncomfortable physicians often make the mistake of rushing into discussion of treatment options, but they should be giving patients a moment to process the news, Leigh says.

“Sit quietly for a moment,” he suggests. “If the patient stays quiet, you can say: ‘I see you’ve been quiet—what are you thinking?’ “

    • Provide a full explanation of the patient’s diagnosis and prognosis before proceeding to treatment. “Don’t plow straight from a bad test result to treatment,” Leigh says. “The patient deserves to understand exactly what’s going on.”
    • Be realistic, but offer some hope. For example, if you’re discussing a malignant mass, you might say that you’re hopeful that the mass will be treatable, but there’s a possibility that it won’t respond to treatment.
    • Make sure the patient understands what you’ve told them, suggests Dr. Miller, who prefers language like the following: “Mrs. Smith, can you tell me what you remember from our conversation so I can make sure I did a good job explaining the news to you?”

    5 comments

    1. This is an important skill and the article was written in a clear, easily useable fashion. The only alteration I would suggest is to ask the patient permission to disclose difficult information or ask how they might receive this difficult information best. This is part of “firing the warning shot” and sets yourself up for success. Thanks for including such a great piece!

      1. Hello Dr. Striegel: Thank you for your kind words about the article. The writer, Rose Raymond, did a great job. Due to space limitations, we were not able to include all the details. I always suggest two questions before giving the news — how much they know and how much they want to know. In your note, you mention, “ask how they might receive this difficult information best.” Do you mean asking about how much to share (i.e., big picture or every detail)? Thank you again, E L

    2. Great article. Instead of saying I know how you feel, (i.e. I know this is hard, which- you don’t know, unless you’ve personally been affected. there are some other phrases, that are less arrogant and self centered making it less about the doctors discomfort and more supportive. Hopefully some other experts will chime in on some good ones.

      1. Dear Lynn John: Thank you for your kind words about the article. The writer, Rose Raymond, did a great job. Thank you for your input about the use of empathy and using the word, “I.” I have been studying the use of empathy in healthcare for over a decade. I have also talked to many experts in the field. Most agree it is acceptable to use the word “I,” however, it is strongly suggested NOT to say, “I know EXACTLY how you feel,” unless the professional has been through the exact same experience. I have interviewed thousands of patients on the topic of empathy and, ironically, they want to hear the word, “I.” They want to know their doctor understands their emotional pain. The biggest problem with empathy is that healthcare professionals feel the empathy inside, but it must be spoken. In my workshops, I say, “We need to move the empathy from our mind to our mouth.” Thank you again.

    3. Great article.
      I insisted to have a bone-scan a few month ago (just turned 51 y.) after my yearly physical. She didn’t want to do it. But I have a family history, so I insisted.
      Results came back a few minutes after test.
      “You have Osteoporosis and it’s pretty bad.”
      I want you to start Prolia.”
      That was it. Oh, she said, keep up your healthy lifestyle.
      And when I asked, are there any side effects. None!
      To be honest, that was not such bad news to get, like a cancer diagnosis, but I didn’t feel treated as I should have been. I doubt, going back to her. I have been a patient for years.

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