How to deliver bad news to patients

A study published in fall 2008 in the Journal of Clinical Oncology sheds greater light on something primary care physicians have long suspected: Give a patient bad news, and he or she won't remember much of what you say after that.

The research, led by Jesse Jansen, a PhD candidate at the Netherlands Institute for Health Services Research, examined 260 patients with cancer who were seeing a medical or radiation oncologist for the first time. Regardless of age, patients with a poorer prognosis recalled less than other patients. In addition, the more information the physician gave the patients, the less they recalled.

Although family physicians usually aren't the ones to deliver news of a terminal disease, the lessons hold for milder diagnoses as well.

Terry Stein, MD, director of clinician-patient communication for the Permanente Medical Group in Oakland, California, says a biologic process occurs when a patient is given bad news. She likes the word "frazzle," used by best-selling author and psychologist Daniel Goleman in his 2006 book "Social Intelligence: The New Science of Human Relationships."

The book, Stein says, explains what happens in the brain during human interaction, as shown on functional MRIs.

"There's now this way to look at brain-blood flow and what happens to our ability to receive information and express ourselves when we're in a state of frazzle," Stein explains. "I've brought that into teaching doctors about communication to help them appreciate that whatever we can do to reduce our own frazzle - and our patients' frazzle or anxiety - is very important."

HOW TO IMPROVE COMMUNICATION

According to Stein, the biggest mistake doctors make when communicating bad news is reverting to "just-the-facts" mode as a defense against their own unease at giving unwelcome news. That defensiveness often leads to a lack of empathy for the patient or a "data dump" - giving too much information, which can be difficult to retain under even the best circumstances.

Another common mistake is using complex language, which can confuse and frighten the patient.

"There's a whole multi-syllabic lingo that's the way doctors talk to each other," Stein says. "They are often words that people don't understand."

Jensen, of the American Academy of Communication in Healthcare, adds that it can be as simple as using the word "cancer" instead of "malignancy." Malignancy is so common to physicians' vocabulary that they often don't realize how many people don't understand what it means.

Dean Schillinger, MD, a primary care physician and general internist at San Francisco General Hospital, studies physician-patient communication in vulnerable populations. Many of the patients he works with are illiterate, poor, and from foreign cultures.

The most effective means of assessing whether a patient has understood the diagnosis and treatment plan is by using the "teach-back" method, Schillinger says.

"It's important that this be done correctly. It's not, 'So, do you understand?' It's really an explicit request that the patient articulate in his or her own words their understanding or reaction to the new information."

The key is to ensure that patients do not feel additional stress, as if they are undergoing a test or being interrogated. To avoid this situation, Schillinger puts the onus on himself as the teacher.

His typical conversation sounds like this: "I want to make sure that I've explained myself well, so just bear with me here. When you go home and talk to your wife or talk to your kids about what my thoughts on what your disease is, how are you going to explain it to them? . . .Because I want to make sure I did a good job explaining it to you."

Jensen refers to this as "chunking and checking" - providing a chunk of information and then checking with the patient to ensure he or she has clearly understood what's been said.