What's the best way to deliver bad news to patients?

'Delivering bad news unsettles everybody, not just the patient,' says expert

Editor's note: This story was updated on January 5, 2018.

How should doctors deliver bad news? Experts say there is no perfect way, but providers can start by acknowledging the sadness of the moment, Sumathi Reddy reports for the Wall Street Journal.

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Breaking bad news is an important part of being a physician; one study suggests oncologists share bad news as many as 20,000 times over their career. Yet, most doctors only receive limited training on how to communicate in such situations, and research has not uncovered an all-encompassing formula for delivering these tough messages.

Tips for balancing medical information and emotional support

Andrew Epstein, a medical oncologist at Memorial Sloan Kettering Cancer Center, runs training sessions for medical students on how to share bad news. He says one mistake to avoid is focusing too much on purely medical information. "If you don't balance out the physiological basis of disease and treatment of disease with the psychosocial side of medicine, you're at risk" of upsetting patients and their families, he says.

Epstein acknowledges that the proper balance of clinical information and emotional empathy is a "moving target." However, he offers six tips doctors should always follow:

  • Find a quiet, private area;
  • Ascertain what patients already know about their medical situation;
  • Get permission to share the news you have;
  • Use silence to recognize emotions;
  • Avoid medical jargon; and
  • Speak precisely, but with sensitivity.

Nila Webster, a stage four lung cancer patient, says, "[b]reaking bad news is actually a golden opportunity to deepen the patient-doctor relationship." She explains, "For a doctor to be willing to be emotionally available is a tremendous gift for any patient."

Does coaching help?

Breaking bad news poorly can hurt patients. James Tulsky, chief of Duke Palliative Care at Duke University, says doctors often "just keep talking and it's just white noise for the patient." Instead, he says, "You need to attend to the fact that this is really serious news and attend to the emotion."

Coaching can help improve a doctor's ability to deliver bad news.  A 2011 study in the Annals of Internal Medicine found oncologists who were given feedback on recorded conversations with patients were twice as likely to use more empathetic statements in future interactions. Moreover, patients reported those doctors to be more trustworthy than those who did not receive feedback.

Yet, a 2013 JAMA study found that doctors and nurse practitioners who received end-of-life communication training were rated no higher by patients than providers who were not trained.  While the best training techniques are unclear, experts say it's a skill clinicians should keep working to improve.

Helen Riess, a psychiatrist at Massachusetts General Hospital and director of the hospital's empathy and relational science program, founded an online training portal to help doctors improve. Riess launched the website after she "noticed that my patients were spending way too much time feeling upset after their medical visits."

The training helps doctors interpret the emotions of patients and their families, but it also encourages clinicians to understand and manage their own emotions. "Delivering bad news unsettles everybody, not just the patient," Riess says (Reddy, Wall Street Journal, 5/18).

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When it comes to end-of-life care, most organizations struggle to meet patients' needs. In a recent poll, 87% of Americans age 65 and older said that they believe their doctor should discuss end-of-life issues with their patients; however, only 27% of those polled had actually discussed these issues with their doctor.

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