Delivering Difficult News

Difficult news can range from something as devastating as a terminal cancer diagnosis to less serious problems such as weight gain. Although skillful and empathic delivery of bad news is fundamental to the health care profession, it is seldom taught in schools.

Even with experience, it may not become easier, but being prepared and having a game plan for delivering bad news can help keep things on the right track. Here are six principles that can help practitioners navigate this task.

1. Establish the right setting

Invite the recipient into a private area, preferably a room with a closed door or an area closed off by curtains. Make tissues available in case the patient becomes upset. Minimize potential interruptions (eg, turn off cell phones). Ask the recipient whether other family members or significant others should be present. All parties should be sitting, ideally with no or few barriers between you and the patient.

2. Gauge reactions

There is no one-size-fits-all way to disclose negative news, so it’s important to pay attention to how the recipient is reacting to the information and then adjust the discussion accordingly. Maintain eye contact, pause frequently, and deliver information in small chunks. Avoid monologues and excessive “data dumps”—a pitfall that can be easy to slip into, especially when the conversation gets uncomfortable. It is also important to remember that although most patients want as much information as possible, not all do. When the diagnostic tests are ordered, ask patients how much information they want to receive back.

3. Offer hope, but be honest

It's important to be honest with patients, but don’t take away their hope. No matter how bad the news is, there is always something modern medicine can offer. Attention can be focused on quality of life and controlling the disease. Some practitioners also find it appropriate to mention that nothing in medicine is certain. Historical records abound with examples of “miracles” that defied all scientific expectations.

4. Focus on today

When patients receive bad news, they often fixate on past behavior, regretting things like diet, lifestyle, or failure to seek medical care earlier. Another common reaction is a sharp focus on what the future may hold. It is important to keep patients grounded in the present and have them focus on the task at hand.

5. Keep patients involved

Recipients of negative news often enter an emotional state in which it is difficult to remember the rest of the discussion. To prevent this, many practitioners draw diagrams, use recording devices, or write down key words, phrases, or dates. It may also help to use the “teach back” strategy, asking patients to repeat what you have just told them.

6. Express support

Patients should know before they leave your office that you will be there to support them. Avoid using phrases like “there is nothing more we can do.” At the very least, medical care can offer pain and symptom management.