How to deliver bad news to patients: 9 tips to do it

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ALEX LI CKERMAN, MD | PHYSI CI AN | JANUARY 2, 2013

1. Prepare yourself to feel badly.Doctors enter medicine with the hope of making patients feel
better. However, when delivering bad news, thats not what happens. No matter how people
feel before I give them bad news, afterward they always feel worse. If I dont recognize this
as normal, that working hard to make people feel good about bad news is not only
counterproductive to the grieving process but potentially deleterious for our doctor-patient
relationship, in the long run Ill add to my patients pain rather than diminish it.

2. Set the context.When delivering bad news of any kind, providing the recipient time to
prepare themselves can be helpful. My attempt to do this with Mrs. Peterson was clumsy
(You know the heart attack he came in for was very serious), but my intent was honest: I
wanted her to realize I was about to tell her something awful. The phrase brace yourself
carries more than a metaphorical meaning in this context. Psychologically, even a single
moment of preparation can mute the pain of hearing bad news, if only a little.

3. Deliver the bad news clearly and unequivocally.I dont say, Theres a shadow on your
chest x-ray or You have a lesion in your lung or even You have a tumor. I say, You have
cancer. The temptation to soften the blow by using jargon is surprisingly powerful
but extremely detrimental. At best, it delays the patients understanding of the truth; at worst,
it promotes their denial of it.

4. Stop.When a person receives bad news, they always have some kind of reaction. Some cry.
Some get angry. Some sit quietly in numbed shock. Some refuse to believe what theyve
been told. My job at that point, however, isnt to clarify, mollify, restate, or defend the
diagnosis or myself. My job is to respond to their reaction and help them through it. I vividly
remember the first time I had to tell a patient and his family he had lung cancer, some time
after my late night call to Mrs. Peterson. I came into the room to find ten or so family
members gathered around my patients bed. I set the context, I delivered the news clearly,
and then I launched into thirty minutes of clarifying explanation. When I finally paused to take
a breath and to allow my patient to react to what Id told him, he only looked at me with a sad
expression and mumbled in a subdued voice, I thought I had more time. He hadnt, of
course, heard a word Id said after Id said the word cancer. The only person Id been
attempting to treat with my soliloquy had been myself.

5. Ask for questions.Once a persons reaction has run its course, or at least paused, I always
ask if they have any questions. Often they dont, at least at first. But often they do. I answer
them all as honestly and directly as I can. Surprisingly, or perhaps not so surprisingly, people
rarely ask the questions doctors dread most: Is this terminal? How long do I have? How likely
is the treatment to cure me?


6. But sometimes they do. When patients ask if their illness is terminal, I tell them the truth:
the percentage of people who survive any illness breaks down into two groups, those who
survive and those who dont. The percentage may be dramatically and tragically skewed
toward those who dont, but I emphasize that no one can predict into which group any
particular patient will fall. One thing Ive learned in my years of practice, both as a doctor and
a Buddhist, is that nothing is certain

7. Never destroy hope except for one thing: if you destroy a persons hope for a good
outcome, theyll suffer far more on the way to whatever bad outcome may be in store for
them than if theyd had the opportunity to approach it full of hope. Especially when the
quantity of life left may be short, the quality of life becomes even more important, and Im
convinced that nothing lessens the quality of life more than living it without hope. How do you
prevent hope from failing when the outcome is so likely grim? I have no ready answer. I often
make statements about the frenzied pace with which new knowledge and treatments are
discovered and once or twice have even seen a new discovery make a difference in a
persons prognosis. But often its what I dont say that allows people to continue to hope. Its
every persons natural tendency to continue to hope even in the face of terrible odds, and
whenever I believe I need to say something that risks interfering with their belief that things
may somehow work out all right, I think very carefully before I speak. I never lie, but neither
do I automatically verbalize everything Im thinking. In general, I try not to enable false hope,
but I always wonder if that does more harm than good. I honestly dont know.

8. Express your commitment of support.I always make a point to say to every person to
whom I deliver bad news, I will not abandon you. I am continually amazed at the level of
relief this provides. Just knowing there is someone in a position of confidence and authority
who genuinely cares about what happens to them, who can explain the things that occur
during the course of their illness and simply be available to them, is enormously relieving to
most people. I also add, if it applies, I will not let you suffer. Adequate training in pain relief
is woefully sparse in most medical schools and residency programs, but the technology
exists to mitigate, if not completely control, the pain of most (though not all) illnesses.

9. Make a plan.I always give patients a series of instructions at the end of a visit in which Ive
delivered bad news. I tell them:
Write your questions down. Once the shock of hearing the bad news wears offusually after
theyve returned homemany questions typically arise. I promise to answer them all, either
on the phone or at our next visit, which I always schedule before they leave my office.
Tell your family. People frequently struggle with this, often thinking first of the impact their
illness will have on their loved ones rather than themselves, and seek to insulate their
familyor specific members of itfrom the news. I am convinced this does more harm than
good in most situations: it prevents damaged relationships from having a chance to heal and
often creates more angst than it resolves, not to mention cuts off critical avenues of support.
People who choose to die with secrets often leave wounds in survivors that never heal.
Prepare yourself for what comes next. It may be more testing. It may be treatment. It may be
both. It may be neither. The last is the hardest to bear, I think. At least while youre engaged
in treatment youre doing something active, fighting the diagnosis in a concrete way. Many
people become inconsolably anxious once their treatmentstops because at that point all they
have left to do is wait for a relapse.

Finally, follow up.Whether by phone or in person, I always talk with the person again within a
week. Often, the person will have made surprising progress in coming to terms with the news
thats been delivered. The human mind has a remarkable capacity to adjust to tragedy, and in
fact I believe begins to cope with bad news the moment its delivered. Many people agree
that the wait for bad news is almost worse than actually receiving it. At least once you receive
iteven if its the worst you fearedyou can begin to take action to deal with it.

The importance of caring
All of us will receive bad newsdevastating newsin the course of our lives, if we havent
already. Studies have shown patients and their families remember the way bad news is
deliveredthe exact words doctors use, how they looked, and whether they seemed to sincerely
carefor the rest of their lives.
Which is why every time Im about to enter a patients exam room to deliver bad news myself I
pause and remember Mrs. Peterson, a woman Ive never seen or heard from since, but whose
life I irrevocably changed in the middle of the night while she lay at home in bed without her
husband next to heras she would from that point forwardall those years ago.