Delivering Bad or Life-Altering News

 

Am Fam Physician. 2018 Jul 15;98(2):99-104.

  See related article from FPM: Communicating Bad News to Your Patients

Author disclosure: No relevant financial affiliations.

Delivering serious, bad, or life-altering news to a patient is one of the most difficult tasks physicians encounter. Broadly defined as information that may alter a patient's view of his or her future, bad news may include information related to a chronic disease (e.g., diabetes mellitus), a life-altering illness (e.g., multiple sclerosis), or an injury leading to significant change (e.g., a season-ending knee injury). Patients prefer to receive such news in person, with the physician's full attention, and in clear, easy-to-understand language with adequate time for questions. Most patients prefer to know their diagnosis, but the amount of desired details varies among different cultures and by education level, age, and sex. The physician should respect the patient's unique preferences for receiving bad news. Physicians may experience stress related to providing bad news that extends beyond the actual conversation. For example, physicians are afraid of eliciting an emotional reaction, being blamed for the bad news, and expressing their emotions during the process. Physicians often withhold information or are overly optimistic regarding prognosis, but this can lead to confusion for patients regarding their condition. There are several algorithms available to help guide the physician in the delivery of bad news, including the SPIKES protocol (setting, perception, invitation, knowledge, emotion, and strategy and summary). Skillful delivery of bad news can provide comfort for the patient and family.

Family physicians, through building long-term, multigenerational relationships with patients and families, often find themselves the bearer of bad or serious news. Bad news is broadly defined as information that will alter a patient's view of his or her future and result in persistent cognitive, behavioral, and emotional responses.1 Some research suggests that alternative terms, including serious news or life-altering news, may be more appropriate.2 Ultimately, the determination of what is bad news lies not with the physician, but with the person receiving the news.3 Although classically related to cancer or a terminal diagnosis, bad or serious news may also include information related to diagnosis of a chronic disease (e.g., diabetes mellitus), a life-altering illness (e.g., multiple sclerosis), or an injury leading to a significant change (e.g., a season-ending knee injury). Most of the research into the delivery of bad news, however, has focused on patients with cancer and subsequently applied to the delivery of bad or serious news in nononcologic settings.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Recognize that the amount of information patients want to receive about their diagnosis varies based on culture, education level, age, and sex.

B

68

Be aware of the stress physicians may experience before, during, and after delivering bad news. Recognize that it may affect interactions with other patients, colleagues, and family.

C

11, 12

When delivering bad news, provide a setting that assures privacy, limits interruptions, and involves family, if the patient desires.

C

2022

When delivering bad news, use nontechnical words and avoid medical jargon. Provide empathy; avoid being blunt and allow time for patients to express emotions.

C

2022, 27, 28

When delivering bad news, respond to patients' emotions as they arise, use empathic statements, validate responses, and ask exploratory questions when the emotion is unclear.

C

28

Use training programs such as communications courses, standardized patient scenarios, and interactive computer courses to improve skills in delivering bad news.

C

3032


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Recognize that the amount of information patients want to receive about their diagnosis varies based on culture, education level, age, and sex.

B

68

Be aware of the stress physicians may experience before, during, and after delivering bad news. Recognize that it may affect interactions with other patients, colleagues, and family.

C

11, 12

When delivering bad news, provide a setting that assures privacy, limits interruptions, and involves family, if the patient desires.

C

2022

When delivering bad news, use nontechnical words and avoid medical jargon. Provide empathy; avoid being blunt and allow time for patients to express emotions.

C

2022, 27, 28

When delivering bad news, respond to patients' emotions as they arise, use empathic statements, validate responses, and ask exploratory questions when the emotion is unclear.

The Authors

show all author info

FRANKLIN J. BERKEY, DO, FAAFP, is associate program director at Penn State Health Family and Community Medicine Residency at Mount Nittany Medical Center in State College. Dr. Berkey is also an associate professor in the Department of Family and Community Medicine at Penn State College of Medicine in Hershey....

JOSEPH P. WIEDEMER, MD, FAAFP, is program director at Penn State Health Family and Community Medicine Residency at Mount Nittany Medical Center. Dr. Wiedemer is also an assistant professor in the Department of Family and Community Medicine at Penn State College of Medicine.

NICKI D. VITHALANI, MD, is a third-year resident at Penn State Health Family and Community Medicine Residency at Mount Nittany Medical Center.

Address correspondence to Franklin J. Berkey, DO, Penn State College of Medicine, 1850 East Park Ave., Ste. 207, State College, PA 16803 (e-mail: fberkey@pennstatehealth.psu.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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