How To Give Bad News
A good stepwise process, for future reference in residency, from a lecture today in Family Medicine. This applies to both deaths and bad news in terms of studies, lab results, etc. (It’s also often a good idea to have the social worker or chaplain with you if you can.)
- Make a setting. Don’t do it in a hallway, go find a private, quiet place to sit and talk.
- Introduce yourself. Often the family has seen a number of different people caring for their loved one–doctors, nurses, techs, etc–so reiterate who you are, especially to the significant other.
- Ask what they know already. It gives you a sense of their knowledge level, what they might be expecting, what they’re worried about, so you don’t repeat anything or speak above or below their level of understanding and medical knowledge.
- Make a “preperatory statement.” This readies and focuses the loved ones for what they’re about to hear. A good suggestion from the lecturer: Don’t say “I have some bad news.” Try, “I have something very important I need to tell you right now.”
- Deliver the news. Be brief, direct, and succinct, 25 words or less.
- Pause, wait for a response. Be there and be present.
- Arrange a follow-up for later. A phone call, a card–it doesn’t have to take extraordinary effort.
- Take care of yourself. It’s emotionally trying and exhausting to do this, so allow yourself to grieve however you may express that, too.
Very good advise. While my profession carriers very little life threatening news, this is still excellent information. Thank you.
This is an excellent, concise review. Thank you for posting. I have to remember to do #7, which I know I should do, but don’t do enough.
Thanks, Graham. The part I found the most insightful was #8. It’s easy for us to get caught up in the rat race,and forget that if you’re so selfless that you never consider what YOU need to thrive in life, you won’t be much good to anyone else.
I might add to avoid euphemisms — he didn’t “pass on,” he “died.” It’s less confusing. Also, I try to make clear that it was the disease (i.e. not the care) that caused the death. i.e. I avoid “We were unable to restart his heart,” but prefer “his heart stopped and did not respond to our efforts to restart it.”
Also, I try to avoid false consolations: “He had a good run, it was his time,” but I do offer meaningful ones: “He did not suffer.”
Also, if you are in the ER, protect yourself. Some families react explosively to unexpected deaths, especially violent ones. Try to stay near the door and make sure you have security within earshot.
If one or more family members starts acting out, a useful tactic is to start talking softly to the most reasonable family member present. They wonder what you are saying, assuming it is important, and sometimes refocus and de-escalate.
Also, It is useful to validate the family’s actions, to the extent it is possible while being honest. i.e. praise their efforts at CPR, tell them how right they were to call the ambulance, etc. The survivors often feel very guilty and it can be therapeutic to know they “did the right things.”
Good post.
In one of my Healer’s Art class sessions, we talked about loss. We wrote an essay about a time when we felt loss and then we wrote some earnest questions that we would ask someone who had just died.
Our teacher took these essays and questions and put them into envelopes. We’re supposed to open them when our first patient passes away. It’s an interesting idea to help with #8 on your list.
This is good advice–most of the time. As someone who is patient rather than doctor, I’m remember a personal experience where I would have prefered no lead up, just the bad news. Of course this was a reoccurrence, but the lead up time just heightened my anxiety as a whole. Minority voice, I suspect, but as another opinion.
But this is good advice, especially the 25 words or less and the no euphemisms comment.
I just recently had this discussion with a 4th year medical student who is going into Oncology. Everything we talked about is mentioned in your post. I believe all the advice given here is great but, #8 is vital. Bruce put it well. If you are not good to yourself, you will not be much good to others. Thanks for post. I hope you have a great holiday. Sarah.
In first year we used a textbook that said, among other things, to preface bad news with the phrase, “I’m afraid I have some bad news.”
When one of us used that line on the standardized patient, we were corrected by our instructor. One person came to our colleague’s defense by saying that it was suggested by the book.
The instructor looked at the line in the book, then said, “Oh, no no no no no.”
We are taught the “SPIKES” protocol for breaking bad news…
It entombs what you recount above in 5 easy to remember letters as,
Setting & Seating
Perception (exploring what the person already knows/suspects)
Invitation (whether the person likes to know the details)
Knowledge giving
Empathising and exploring emotions
Summary