Everyone has to deliver bad news now and then, but as a radiation oncologist, doing so is a core function of my job.
Many published pieces in the medical literature describe effective strategies. A number of them have catchy mnemonics like SPIKES or ABCDE (physicians love mnemonics). And they all generally come down to the same pieces of advice: Build a relationship. Speak frankly and honestly, but with compassion. Show empathy.
I agree with all of these concepts, but I have also learned more practical steps for delivering bad news throughout my 15 years in practice.
Telling a patient that her PET scan shows cancer progression or that she will need further radiation after surgery is worse news than most people deal with at work, but I believe that the best practices for doing so could also be applied to delivering other types of bad news compassionately. Whether announcing layoffs, telling an employee he was passed over for promotion, or delivering bad quarterly sales results—some thought can help make the experience less painful for all involved.
Plan ahead: Before an appointment with a patient, I review the case, films, and facts. I speak to any other physicians involved whose opinions I need to make a final decision. All of this needs to be done before the appointment, so that the meeting is smooth and the advice is clear.
I also make sure that the meeting takes place in an environment where it’s comfortable to talk and have tissues ready in case of tears.
Deliver the news with minimal preamble: Don’t keep someone waiting for bad news. A short, few-word phrase to prepare people to hear bad news is appropriate, but do not give a long preamble before coming to the point. That preamble is just torturous time for the patient, and subconsciously or consciously, you are using it to stall.
Be direct: Try not to couch it in jargon or technical language that may cause the patient to stumble. Choose your words carefully and do not equivocate where it’s not appropriate.
Pause: In my experience, allowing for a pause after the delivery of bad news is a wise practice. People will need a few moments to compose themselves and their thoughts. A short period of silence can be helpful. Additionally, most people will not hear anything you say for at least a few seconds, and up to a few minutes, after hearing significant bad news. Allow them a moment for that to pass. Realize your desire to move on quickly after giving bad news is the flipside of the desire to give a long preamble. It is a way to get your own painful experience (being the deliverer of bad news) done with as quickly as possible, when at that moment the focus needs to be on what’s best for the patient.
Express empathy: There are many ways to express empathy both verbally and physically after giving bad news. My advice is to keep your expression simple at this time. Don’t presume you know what someone is thinking or feeling. A simple “I’m so sorry,” a gentle hand on the back or leg, and a long, deep hug are all meaningful. Know yourself and the patient, and be genuine. This is the time to really, deeply mean what you say or do, and to let that feeling show through. Give the patient a chance to express their emotions, feelings, and fears. Listen closely to what he or she says.
Answer questions: Give an opportunity for the patient to ask questions, and answer those questions with honesty.
Know the next step: People usually handle bad news better than you think they will, but they want to know what’s next. Try to have concrete plans in place. If a patient needs to see a surgeon, I’ll let him know I’ve already spoken to the surgeon ahead of time and have set up a visit. If there are no more good treatment options and hospice is the next best step, I’ll let him know we will have the hospice ready to meet him in the next 48 hours. Whatever it may be, don’t give bad news and then send the person away. Give bad news, and then provide a plan or options for how to address the future.
Once you’re alone, give yourself time to process: While you initially need to resist doing things that will ease the burden on yourself at the expense of the person receiving bad news, you should embrace those impulses after the person has left. Remember that anger is the second Kubler Ross stage of grief and accept that if the recipient of bad news got angry or even expressed hatred towards you, that’s often a normal reaction and not a reflection on you. Take time to reflect and sort through your own emotions of fear, guilt, and pain.
Andrew Neuschatz is a physician and partner with Arizona Oncology in Tucson, AZ.