The Rules for Delivering Bad News to Patients

[surgblumm]

 I found this in the beginning of the year and pasted it to my desktop. I discovered a question concerning this subject on one of my PA sites and since I cannot remember which one, I will place on my favorite site.

The Rules for Delivering Bad News to Patients

August 27, 2019

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I've talked to some colleagues recently who've been a little down about their roles as nurse practitioners. Working in family practice, they have found themselves in the position of delivering bad or upsetting news to their patients. Cancer diagnoses were fortunately made rather than missed, but letting a patient know they've got a serious, life-altering illness or condition is tough, not to mention, this is not something most of us as NPs learn to do in school. 

Have you ever found yourself in the position of delivering difficult news to patients? How did you feel? Having such conversations as nurse practitioners can make us anxious or awkward. Some of us approach these discussions emotionally while others appear detached and robotic in their delivery of the news. Delivering bad news is an unavoidable part of our jobs as nurse practitioners but that doesn't mean we get used to it. Fortunately, however, conducting serious conversations is a skill that can be learned and there are many guidelines out there to help healthcare providers hone this skill set. 

Rule #1: Know what constitutes bad news

Sometimes I share information with a patient that I perceive as not a big deal. Then, the patient starts to freak out. Or cry. Or to have some other sort of emotional reaction that I didn't anticipate. Bad news doesn't have to be a terminal diagnosis. It can be related to anything surrounding a diagnosis such as timing, personal or professional consequences. Breaking a metatarsal and wearing a boot, for example, may not be too bad in the grand scheme of things, but breaking your foot the day before your wedding is pretty disappointing. 

Rule #2: Full disclosure is best

In the past, healthcare providers operated on a more guarded front. In the 1800's, for example, the American Medical Association even encouraged physicians to avoid sharing news that discouraged patients. Today, however, studies (not to mention ethics!) show that most patients prefer full disclosure. It's our duty as nurse practitioners to share up-front, honest information rather than sugar coat our delivery with excessive optimism, withhold details, or give false hope. Share news with the patient directly rather than directing it toward family members. Honest, trustworthy information is empowering! 

Rule #3: Prepare yourself

Anticipate the conversation you're about to have with your patient. You may even wish to practice your delivery with a colleague. Prepare yourself to feely badly as you share the news. And, don't forget that silence is OK. Avoid the temptation to fill gaps in your conversation rather let the patient process and take the time to formulate questions. 

Rule #4: Frame the conversation

Framing the news you're about to share is essential. Your patient may or may not be expecting to hear something difficult. And, the way you set up your conversation has an impact on the patient's reaction. Using the word "serious" (ex. "I have some serious news to share...") is better than using the word "bad". "Serious" creates a more constructive framework that inspires action and empowerment as opposed to the word "bad" which indicates the situation is helpless. Even if you're delivering a terminal diagnosis, your patient can choose how to react and what steps they wish to take in response. 

Rule #5: Think SPIKES

There are a few well-known methods for delivering serious news to patients, my favorite of which is the SPIKES method. This algorithm lays out considerations for nurse practitioners and other healthcare providers in these situations. Here's the SPIKES protocol:  

Setup - Think through the conversation you're about to have, anticipating questions the patient might ask beforehand. Prepare for an emotional reaction. Gather any necessary resources that might be helpful for the patient. 

Perception - Gauge the patient's understanding and perspective on the news you have shared. This is best accomplished by asking questions like "What did you take away from what I just shared with you?" or "What are your expectations of treatment?". This way you know you are both on the same page as far as understanding the medical outlook, next steps and goals. 

Invitation - Encourage the patient to think further about their care going forward. Find out how much information the patient wants about his or her medical condition as well as who he/she would like to be included in decision making such as family members. 

Knowledge - This step has to do with how you as a provider deliver information. The best practice is to deliver the headline first, followed by the details. Communicate using language that matches the patient's level of education and medical knowledge. Be direct in your delivery, avoid skirting the main message. 

Empathy - Understandably, patients get emotional about serious news. Anticipate such a reaction and display empathy. Naming the patient's emotions can help. Asking "Can you tell me more about what you mean by that?" will also help you determine how the patient feels about the situation. 

Summarize and Strategize - Make a plan for the next steps in both treatment and communication with your patient. Express support and encourage the patient to tell friends and family the news to develop a personal support system. Talk about how the patient can act on this news to accomplish his or her treatment and lifestyle goals going forward. 

Have you ever delivered bad news to a patient? How did it go?

[SedRate]

15 minutes ago, surgblumm said:

 

Have you ever delivered bad news to a patient? How did it go?

 

Daily in my last practice in ortho trauma where we not only took care of Level 1 trauma pts but also referrals for infections and nonunions. Most bad news involved telling them they have broken bones, bone infection requiring PICC and IV antibiotics, nonunion requiring extensive revision and grafting, prosthetic joint infection requiring extensive treatment and revision surgeries, amputation, etc. It's hard for patients to hear that they require surgery (especially if it's multiple surgeries and an extended hospital stay) and/or they'll be down for an extended period of time to recover, especially complex patients that require multiple procedures, lots of therapy, and time off from their work, family duties, or activities/hobbies. Even though most of these patients get better to some degree at some point, patients often have a hard time focusing on the end goal and instead focus on all the barriers in between. I think this has a lot to do with our current culture of instant gratification and convenience, which is almost the antithesis of recovering from any of the above conditions. 

My surgeons were busy operating, and so I was usually the one discussing findings and treatment plans and coordinating care. The conversations would go ok. Despite how well the surgery might've gone, patients don't like hearing they won't be able to fully use their limb for an extended period of time and will be out of work for anywhere between 6 weeks to 4+ months for treatment and recovery. Add to that the pain, cosmetic appearance, possible loss of their vehicle and/or loved ones, medical bills, and any other social issues they encounter, it is a very trying time for patients and their families. I don't think patients realize what kind of work is required to get healthy, even in this day in age of medicine. Yes, we have lots of medical advances, especially in Ortho, but it still requires a lot of work and patience on the patient's part. Add to that the myriad of issues related to barriers in medical treatment such as non-compliance and comorbidities, it becomes a more complex issue. This, of course, can be translated to other specialties.

[ohiovolffemtp]

Bob,

There is also a discussion on this topic in the Huddle.

I do EM, so delivering bad news comes with the territory.  The worst 2 versions are death notifications and informing patients of newly discovered advanced diseases, most commonly likely cancer.  Unfortunately, in the EM world, this discoveries are often made when imaging shows likely metastatic disease.  Here are some things I've found:

• We didn't cause the bad news, we're the ones who discovered it.  This is very important to our mind set.  We only have control over how the news is delivered and how to start the plan for what comes next.  We can't make the news any different.  We can deliver it in a compassionate manner.
• The news has to be delivered in lay person and unambiguous terms.  "has died", "there's a good chance that what the CT shows is cancer that has spread", etc.
• The patients and their family will have lots of questions.  Many of them are around what comes next, or how will they learn more.  We should know how to start that process: admission with consults to heme/onc or other relevant specialists, whether it's a coroner's case, who will help them with what funeral home to call, etc.  We must show them there is a plan, and who will help them through the 1st steps.

At least I had a fair bit of experience with doing notifications as a medic - that helped me do these in the ED.

As for how did each one go: for calibration, the answers should range from "not very badly" to "very badly".  The overarching reality is that the news is bad and that is what really matters to the patient.

[cinntsp]

I give it all the time as a hospitalist.  Explain it fully and in clear terms.  Don't try to beat around the bush or soften the blow...just be honest.  My biggest piece of advice is to pull up a chair and sit down next to the patient and family when you tell them.  Give them the appearance that you aren't in a hurry and are there for them.

[thinkertdm]

 

[TWR]

The Huddle comment  was excellent in my opinion.

[cbrsmurf]

On 12/12/2019 at 8:08 AM, ohiovolffemtp said:

Bob,

There is also a discussion on this topic in the Huddle.

I do EM, so delivering bad news comes with the territory.  The worst 2 versions are death notifications and informing patients of newly discovered advanced diseases, most commonly likely cancer.  Unfortunately, in the EM world, this discoveries are often made when imaging shows likely metastatic disease.  Here are some things I've found:

• We didn't cause the bad news, we're the ones who discovered it.  This is very important to our mind set.  We only have control over how the news is delivered and how to start the plan for what comes next.  We can't make the news any different.  We can deliver it in a compassionate manner.
• The news has to be delivered in lay person and unambiguous terms.  "has died", "there's a good chance that what the CT shows is cancer that has spread", etc.
• The patients and their family will have lots of questions.  Many of them are around what comes next, or how will they learn more.  We should know how to start that process: admission with consults to heme/onc or other relevant specialists, whether it's a coroner's case, who will help them with what funeral home to call, etc.  We must show them there is a plan, and who will help them through the 1st steps.

At least I had a fair bit of experience with doing notifications as a medic - that helped me do these in the ED.

As for how did each one go: for calibration, the answers should range from "not very badly" to "very badly".  The overarching reality is that the news is bad and that is what really matters to the patient.

Do y'all in EM tell patients they have cancer without a tissue/pathology diagnosis?  I can certainly be very suspicious based on history, scan, and symptoms, but I never tell patients they have cancer for sure without tissue diagnosis because sometimes it can look like cancer and it's not.

[ohiovolffemtp]

1 hour ago, cbrsmurf said:

Do y'all in EM tell patients they have cancer without a tissue/pathology diagnosis?  I can certainly be very suspicious based on history, scan, and symptoms, but I never tell patients they have cancer for sure without tissue diagnosis because sometimes it can look like cancer and it's not.

Good question:  no, what I tell patients and their families is that the imaging saw X which is very concerning for cancer.  I also tell them that the definitive diagnosis requires follow-up examination and workup by specialists and likely a biopsy.  Next, I tell them what the plan is - usually admission - to get that done.

[surgblumm]

There have been really excellent responses to this query on physicianassistant.com and a plethora of responses focused on many aspects that one usually is not thinking about as in relation to jobs, family, loss of limb, unemployment, funeral arrangements, etc. These were very outstanding. I tried to post this on Huddle also, but usually find it difficult or I get a hart time therefore I AM THINKING OF FORGETTING hUDDLE ALL TOGETEHR. tHANKS FOR YOUR MANY COMMENTS WHICH SHOULD HELP OUR COLLEAGUES AND MAYBE SOME OF THESE RESPONSES AND THIS POST CAN BE SENT TO hUDDLE FROM SOMEONE WHO IS MORE USER FRIENDLY. Sorry, I did not see that the Caps were struck.