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In this day of selivering bad news, I thought that this article that I saved from last year would be a great refresher. Food is food regardless of the source.



The Rules for Delivering Bad News to Patients

August 27, 2019

The Watercooler: Career Advice

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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?

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This is such an important topic. 

Unfortunately in my experience in neurosurgery, I've had to deliver a significant amount of bad news, including new cancer diagnoses, devastating intracranial hemorrhage, paralysis and death. It's never easy but it does get better with practice. Some points I've found helpful for this discussion...

1) Complete your history and physical before delivering bad news. Once you've said your piece, the patient and family are distracted, tearful, angry and will not listen or focus on you at all. Your PE will just irritate them at this point. 

2)Communicate to the patients care team, including primary team and nurses that you've made the patient aware. The team can sometimes dance around bad news, not wanting to deliver it or confirm that the patient knows it. 

3) If the bad news is not an impending mortality, emphasize that they are starting a journey, exploring options, regrouping, "finding more answers". This encourages hope and allows a distraction from the awful diagnosis. 

4) Finish off by asking, "what questions do you have right now, if you want to take your time, collect your thoughts and then ask, I will be here for you when you're ready". Patients can be overwhelmed and cant think straight to process their thoughts. 

5) Offer to call and explain it to family. Patients sometimes dont trust themselves to relay things accurately. Only call family if necessary for consent/goals of care or expressly told to by patients. They have their own reasons for including or not including people in their healthcare. 

6) Do not offer information you do not have. Even if pressured. This includes diagnosis and prognosis. 

7) Finally, if you have to deliver news of a death, be as honest and final as possible. Give a brief history of events and then only the details that family specifically asks for. Document the whole event of course but at the time of delivering news, dont list every vital, every medication that was tried or exactly how the patient died. It's not the time.  

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1 hour ago, NeurosurgPA17 said:

1) Complete your history and physical before delivering bad news. Once you've said your piece, the patient and family are distracted, tearful, angry and will not listen or focus on you at all. Your PE will just irritate them at this point. 

I would also say that the family would likely assume that your assessment was not thorough if you then continue to examine the patient.

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In both EM and fire/EMS I've delivered bad news, often death notifications, many times.  Here are some other things that I find helpful:

  • the news is bad.  You didn't make the news, you're just reporting it.  (corollary: if you made the bad news - don't be the one to report it).
  • You aren't in control of the news, only of how it's reported, i.e. in the most caring fashion possible.
  • You aren't in control of the response: that's largely a function of the audience.
  • Be prepared to give a short version of what happened.
  • The audience will have lots of questions about what comes next.  Answer the ones you can, tell them how or who can answer those questions.
  • Pause, then ask them what else they want to know.
  • Leave them with knowledge of who's going to interact with them next.
  • Upvote 1

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