On Delivering Bad News

By Kate Schiff, MHS, PA-C

Kate SchiffOne challenge all medical practitioners face is how to deliver bad news to their patients. During my five years as a PA, I have been the beneficiary of excellent advice on how to do this. But, from time to time, I have wondered whether there may be something I could do to better comfort and communicate with patients during these difficult moments.

For guidance, I turned to Dr. Gerard Fumo, medical oncologist and hematolgist at Midstate Medical Center. “Sit down, sit close, don’t rush, remove distractions and don’t allow interruptions. Watch your patient closely as you talk. Make sure you are not losing them,” Fumo advises. “Pause if necessary, let them absorb what you are saying. Frequently people stop processing when they get bad news…don’t be uncomfortable with a little silence. This is where you can ‘read’ the situation – is your patient coping well or decompensating? You will proceed differently based on how you read the situation.” The ability to read the situation is critical, and patients will notice when their provider fails to do so even if the patient appears distracted by their diagnosis. When labor and delivery nurse Amy Murlowski received news that she had a progressive, degenerative spinal disorder, she explains she wished her spine specialist had “simply acknowledge[d] the shock and discomfort” Amy was in due to both the diagnosis and her level of pain at the time.

Patients watch their medical providers closely, and read their demeanor for clues to the diagnosis. Breast cancer survivor Kimberly Jones* describes her first doctor's visit after a breast biopsy: “When the initial biopsy came in, she checked [the biopsy site] and never looked at me. We have a history of friendly banter usually with each other…I already knew it was bad.” She recalls feeling alarmed and offended by the sudden loss of friendliness and withdrawal. Later, when pathology revealed her cancer to be worse than what she had initially understood it to be, Kimberly resisted returning to the office to discuss her treatment and prognosis. “I said call me, I can read your body language so not looking at me doesn’t work for me. She said ‘well I don’t like to give bad news’…in my heart I want to say I’m glad she has not been desensitized, but in my head I’m like my God it's your job to inform me of everything…”

While tact and body language are extremely important, the greatest nuance lies in knowing the right amount of information to give the patient. To gauge the proper amount, Dr. Fumo suggests observing how comfortable the patient is with the conversation. “You don’t always have to give all the bad news in one meeting. Some individuals just can’t cope with it and others don’t do well with bad news that just seems to be getting worse and worse. Many times bad news can be given in stages.” He also cautions health care professionals to be aware of the influence of accompanying friends and family. “It’s great to make sure that family and friends are getting what they need from the conversation, but your first obligation is to your patient. Even as you address family’s questions, always keep an eye on your patient and make certain your patient is comfortable with how things are going. Stay at the pace of your patient, not the family or friends.”

My hope is that this essay will provide some useful tools, insight, and reassurance for a distressing medical moment. In conclusion, I offer one last pearl from Dr Fumo: “Be sincere and empathetic. Patients sense whether you are just giving them standard recommendations…or whether you’re giving them individual care and guidance based on medical information. Earn their trust and guide them with your heart and instinct; you have the knowledge.”

*Name changed at patient's request.

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