Commentary by Parul Gandhi MD, PGY-2
Bad news can be defined as “Situations where there is either a feeling of no hope, a threat to a person’s mental or physical well-being, a risk of upsetting an established lifestyle, or where a message is given which conveys to an individual fewer choices in his or her life.”(1)
As residents, we spend our time caring for patients and their families. Despite all of our valiant efforts, though, there are times when we must deliver bad news. By now, all of us have faced the challenge of delivering bad news to a patient. During medical school, many of us practiced this skill in artificially created scenarios, but we agree that no amount of practice could have prepared us for the complexity of the real life situation. In addition to the innate difficulty in delivering bad news to patients, residents also face many personal and institutional barriers that complicate an already infestive circumstance. The following is a summary of challenges residents potentially face and the approaches that have been studied to start overcoming these barriers.
Bad news is not new to medicine, but how physicians deal with it has changed significantly over the past 30 years. We have shifted towards patient autonomy and away from the paternalistic practices of the past.(2-4) Active patient participation in the care plan improves compliance and quality of life.(5) The increasing role of residents as patient educators has accompanied the movement towards greater patient autonomy. The role of delivering information, good and bad, is largely filled by residents in academics. Despite this, numerous studies have shown that residents from a wide range of residency specialties feel insecure about their abilities to deliver bad news.(6-9) Given that residents often have the most direct contact amongst the healthcare team, giving bad news is a skill which residents need to feel comfortable performing.(10)
In one study, focus groups of different specialties identified barriers to delivering bad news from a resident’s perspective.(9) They identified the following: inadequate time, fears of making a mistake or not showing enough empathy, personal biases and opinions towards the disease, uneasiness with the topic of death and dying, and a lack of support from other members of the healthcare team. Other challenges include the language barrier, cultural differences, and giving prognostic information, as prognosis is often overestimated in these types of discussions.(10) Finally, residents do not have long term relationships with their patients and often feel that they are giving bad news after only knowing a patient for a short time period.
Identifying barriers is important because it allows for possible solutions (see table 1) Take for example, inadequate time, which is probably the most significant institutional barrier felt by residents. A possible solution to this is setting aside time for family meetings when predictable interruptions can be minimized to allow the meeting to be short but effective. Another challenge stated in one of the aforementioned studies is a fear of not showing significant empathy. Residents have difficulty identifying the patient’s perspective on their disease.(8) A possible technique to alleviate this is asking open ended questions early on to determine the patient’s agenda and identify their emotions. Residents have their own fears and biases regarding these situations. To be truly prepared for each situation, a resident needs to gather adequate information for the patient as well as being emotionally prepared personally for a possibly difficult interaction. After the conversation is complete, a debriefing with the attending or a mentor can be very helpful. By processing what has happened, the resident can feel a sense of growth and closure from the present interaction and avoid affecting future similar experiences.(9)From a systems perspective, it is important to inform everyone on the healthcare team about any planned discussion and to include any members who are directly involved.(9) When speaking to patients who speak another language other than English, the use of professional interpreters is preferred. The interpreter should be informed about the type of conversation and whether literal interpretation or “cultural brokering” should be used.(12) There is no “one size fits all” approach in determining how much information should be disclosed and with all interactions, regardless of cultural differences, the patient’s preference should be determined and respected.(10)
In conclusion, delivering bad news is an integral part of our careers. By acknowledging it as an area of weakness, we can work to improve both our abilities and our confidence levels. Residents face unique challenges when giving bad news. Identifying mentors to discussing our personal views and feelings in regards to each bad news interaction is imperative to help us process our own emotions and improve future interactions of this type.
Table 1. ABCDE protocol by Rabow and McPhee (2)
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Advance Preparation
Build a Therapeutic Environment/Relationship
Communicate Well
Deal with Patient and Family Members
Encourage and Validate Emotions (reflect back emotions)
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References:
1. Bor, et al. The meaning of bad news in HIV disease: counseling about dreaded issues revisited. Counseling Pschol Quarterly. 1993; 6: 69-80.
2. Baile W, Buckman R, et al. . SPIKES- A six step protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist. 2000; 5:302-311.
3. Fallowfield, L, Jenkins, V. Communicating sad, bad, and difficult news in medicine. The Lancet. 2004; 363: 312-319.
4. Vandekieft, G. Breaking Bad News. American Family Physician. 2001; 64:1975-1978.
5. Zachariae, R et al. Association of perceived physician communications style with patient satisfaction, distress, cancer related self-efficacy, and perceived control over the disease. British Journal of Cancer. 2003; 88: 658-665.
6. Girgis, A and Sanson-Fisher, R. Breaking Bad News 1: Current Best Advice for Clinicians. Behavioral Medicine. Summer 1998; 53-59.
7. Pauls, M and Ackroyd-Stolarz, S. Identifying Bioethics Learning Needs: A Survey of Canadian Emergency Medicine Residents. Academic Emergency Medicine. 2006; 13:645-652.
8. Eggly, S., Afonso, N, et al. An Assessment of Residents’ Competence in the Delivery of Bad News to Patients. Academic Medicine. 1997; 72:397-399.
9. Dosanjh S, Barnes J, and Bhandari, M. Barriers to breaking bad news among medical and surgical residents. Medical Education. 2001;35:197-205.
10. Barclay J et al. Communication Strategies and Cultural Issues in the Delivery of Bad News. Journal of Palliative Medicine. 2007;10:958-977.
11. Rabow M and McPhee S. Beyond Breaking Bad News: How to Help Patients Who Suffer. West J Med. 1999;171:260-263.
12. Norris W, Wenrich M, et al. Communication about End-of-Life Care between Language-Discordant Patients and Clinicians: Insights from Medical Interpreters.
Image courtesy of Ehrman Medical Library. Bellevue Hospital-East River View. A view of the hospital from the East River, in 1879.