In this issue of American Family Physician, VandeKieft discusses breaking bad news to patients.1 The increased importance noted by current literature in family medicine on end-of-life issues reflects the desire on the part of society to collaborate with their family physicians in dealing with such issues.
Breaking bad news is a sentinel skill of the family physician. Family physicians who provide continuity care to patients are in an ideal position to compassionately, yet clearly, convey devastating news. The importance of the physician-patient relationship in such engagements is critical.2 Having already developed a sense of mutual trust, the family physician is often in the position to break such news.
Breaking bad news as it relates to terminal illness also marks the beginning of a long and tumultuous journey that the physician and patient take together.3 The patient relies on the physician to provide appropriate medical care and advice, as well as provide appropriate psychosocial support. Physicians must balance a duty to provide this care for the patient while continually reevaluating their own response to the patient and family's crisis.
The ABCDE (Advance preparation, Building a therapeutic relationship, Communicating well, Dealing with the patient and family reactions and Encouraging/validating emotions) mnemonic works well in organizing a physician's approach to breaking bad news. The advanced preparation portion is critically important because it will lay the factual basis and foundation for the conversation to continue. Review of pertinent medical facts in collaboration with appropriate consultants should prepare the physician for providing information to the patient. Knowing the patient as an individual and human being is a critical factor in assessing how the bad news will be conveyed.
Assessing what the patient wants to know and what the patient knows already can serve as a step-off point to begin the discussion. Ideally, discussing this issue during the informed consent portion of a diagnostic procedure can include the phrase: “if we find something, how would you like me to tell you?” This can also serve as a way to initiate the conversation.2 For example, “as we talked about when we went over this procedure, you had asked me to tell you straight.” In preparing for the discussion, the selection of a quiet room with minimal interruptions is essential. After communicating the bad news in a clear, understandable, culturally sensitive way, the physician must be prepared for the patient's and family's reactions. Occasionally, the family insists that the physician not tell the patient, fearing the news would be too much to handle.
The family physician has a legal obligation to obtain informed consent from the patient and a duty to inform the patient of the news, unless the patient refuses. Ideally, the physician can take advantage of the knowledge of the family to promote a congenial family alliance. Asking the family why they don't want to tell the patient can uncover relational issues and dysfunctional family dynamics.4 The family physician must be prepared for the wide range of emotions available for the patient and the family. These may vary from loving acceptance to anger and rage. When emotions are communicated to the patient, it is important to listen quietly and intently, with specific attention to the emotional description of feelings. In addition to verbal communication, nonverbal communication, including open body language, is important. It is essential for family physicians to be culturally sensitive to the patient and the family when discussing such important news. Having appropriate family members or other support personnel present is important.
If language is a barrier, wait for a translator to be a part of the discussion. It is also important to assess the patient for inappropriate coping skills, such as suicidal or homicidal ideation.5 Finally, the physician must be able to assess personal emotional reactions to the conversation. Appropriate support from family, colleagues, and other appropriate people is critical for the continued effectiveness of the family physician. In our profession, we cannot afford a long learning curve when it comes to basic skills in end-of-life care.6 Courses and seminars concerning end-of-life care and spirituality are becoming more prevalent. One is a joint venture between the American Medical Association (AMA) Institute of Ethics and the Robert Wood Johnson Foundation entitled Educating Physicians on End-of-Life Care (EPEC).7 More information about the curriculum for the 16-hour basic course on end-of-life issues is available through the AMA. In addition, courses are available throughout the country providing EPEC training to interested family physicians, other primary care professionals, and allied health care workers.
Breaking bad news is an essential skill of any family physician. Our training and values support open and honest communication between the physician and patient. As a result, family physicians are in an ideal position to help patients with a terminal disease face their illness with compassion and dignity.