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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