The FACES Foundation Lecture Series

Delivering Bad News

Howard Beckman, MD, FACP, FAACHClinical Professor of Medicine and Family Medicine

University of Rochester School of MedicineNovember 15, 2012

Objectives

Promote an approach centered on understanding and responding to the patient & family

Emphasize the importance of listening Provide a stepped approach to delivering bad

news that begins with clarity about the key message to be shared

Incorporate the principle that only the patient/family can decide which news is bad

Delivering Bad News

Recall an experience of delivering bad news that is memorable to you.

Why does that particular experience come to mind?

Turn to another person and share the story and why you chose

to share it.

Historical Approaches to DBN

“...conceal most things from the patient while you are attending him. Give orders with

cheerfulness and serenity, turning attention away from what is being done to him [because] a forecast of what is to come can cause a turn

for the worse.”

Hippocrates, Decorum

Historical Approaches to DBN

“Promise health to the patient who is hanging on your lips but intentionally exaggerate the peril of the illness to the family. If the patient recovered, the physician was assured ‘you will be praised more for your art; should he die his friend will testify that you had given him up’.”

Arnaud of Villanova - (14th Century Physician)

Historical Approaches to DBN

“The life of a sick person can be shortened not only by the acts, but also by the words or the manner of a physician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have a

tendency to discourage the patient and to depress his spirits.”

First Code of Medical Ethics Am. Med. Assn., 1847

Historical Approaches to DBN

#13 “In my practice, I’m doing heart surgery all the time so I talk to families. I always tell the nurses

and tell everybody, paint the gloomiest pictures you can because if they do ok, I look like a hero. And if

things don’t go so well, then there is kind of a respect in that, you know. I may know that the case went fine, the patient is going to be fine, there are not going to be any problems. But I never ever say

that to the patient or to the family. Always say, ‘well, it was a tough case and

I think he’ll pull through’.”Levinson, et al, 1993

Defining Bad News

Information that Significantly Alters a Person’s View of the Future

Kelly CK, Bearing Bad Tidings. ACP-ASIM Observer. Jan. 2003

Common Fears About Delivering Bad News Causing pain and/or sufferingBeing wrong or giving incorrect informationExtinguishing hopeConfronting one’s own mortalityEliciting profound emotions: one’s own or the patient’s Fear of saying, “I don’t know”

Common Errors in Delivering Bad News

Not attending to the need for privacy Failing to solicit patient’s understanding of the issue in question before delivering the newsNot asking about the depth of information the patient or family wants to knowDelivering excessive information–“the lecture”Giving premature reassurance, “It’s going to be fine… I’d worry about something else”

Common Errors in Delivering Bad News

Trivializing emotions :“Many patients have struggled with this. I know how you’re feeling”

Prioritizing physical over emotional concerns

Failing to respond to intense emotions; missing empathic opportunities (Suchman et. al.) or missing clues (Levinson et al)

Common Errors in Delivering Bad News

Failing to assess changes in the patient/family’s attitude or desire for information over time

Assuming the valence of the news on the patient/ family Failing to coordinate with other teams… “I didn’t realize

the ICU nurse suggested hospice” Arguing or bargaining with a person or family in denial

or anger; missing the patient’s/family’s “stage of change”

Stages of Change

April 10, 2023 ©2011 Focused Medical Analytics, LLC 13H. Beckman, MD. et al. AJMQ, 2006. Adapted from E. Kubler-Ross

Guidelines for Delivering Bad News:Preparing

1. Review the record: what’s previously been discussed?

2. Solicit staff’s view of the patient’s understanding of the problem

3. Determine if the patient has expressed how information s/he wants to know at this time

4. Learn the details of the case

Guidelines for Delivering Bad News:Setting Up the Environment

Choose a comfortable, quiet, private location Avoid physical barriers like desks & tray tables

Schedule enough time for content & emotion

Formulate the message you want the patient/family to remember

Select the Message Carefully

Guidelines for Delivering Bad News:Opening the Interaction

Determine who the patient wants involvedCheck for patient’s/ family’s understanding of the issue before

beginningElicit how much information the patient or family wants to

know at this timeIdentify the message you want the patient or family to

rememberSay that message FIRST: “You have a treatable condition”… “We

will make you as comfortable as possible”… “We’re here for you”

Guidelines for Delivering Bad News:Delivering the News

Then deliver the news you think is badWait for the response; do not fill the silence with your opinion or reassuranceRemember, often the patient/ family “hears” nothing after the news is deliveredWhat is most remembered by the patient or family is your response to their emotions

Guidelines for Delivering Bad News:Leading the Interaction

Let the patient/family decide if the news is badReactions vary depending on age, education

religious/ cultural values, previous expectations Wait for the patient/family to digest the

information and the valence of the news

Guidelines for Delivering Bad News:Creating Meaning

Give the patient control over timing and quantity of information – observe NVB, listen

Tailor the discussion to the concerns expressed by the patient or family

Encourage questions and thoughtsAvoid lengthy explanations When unsure, say so, “I’m not sure, let me

look into that and get back to you”

Guidelines for Delivering Bad News:Concluding the Interaction

Ask how the patient/family is doing

Work towards a mutually agreed upon plan

Summarize follow-up tasks to achieve the plan

Follow up time will be needed; agree on a plan for providing access

Leave room for hope Encourage patient or family to write down

questions as they ariseRepeat the core messageEmphasize that there will be follow-up

opportunities to talk

Guidelines for Delivering Bad News:Concluding the Interaction

Check back with patient/family a short time after the meeting

Take care of yourself – seek support, acknowledge your feelings

Guidelines for Delivering Bad News:Following Up

Delivering Bad News

Now apply the principles from this session to the interaction you described earlier.

1.What is the message you want to deliver? 2.Deliver the news 3.Rather than speak after the news, wait and listen for your partner’s response(s).4.Respond to any emotion expressed.

Contact Information

Howard Beckman, MD

Clinical Professor of Medicine and Family MedicineUniversity of Rochester School of Medicine

Howard_Beckman@urmc.rochester.edu585-341-6775