CLEVELANDCommunicating bad news is an essential part of
end-of-life care as well as an important skill in all areas of
medicine. Although many physicians feel unprepared to deliver bad
news, it is a skill that can be learned and improved, said Donna S.
Zhukovsky, MD, director of the Cancer Pain Clinic in the Palliative
Medicine Program, Cleveland Clinic Foundation.
Dr. Zhukovsky spoke at a conference devoted to the clinical
management of terminally ill patients. The conference was based on
the Education of Physicians in End-of-Life Care (EPEC) program,
developed by the American Medical Association in conjunction with the
Robert Wood Johnson Foundation. Conference participants were divided
into small groups for a discussion of communicating bad news and the
presentation of a video produced by the EPEC program.
Breaking bad news begins before the patient arrives, Dr.
Zhukovsky said at one such group discussion. The physician should
plan what he or she is going to say and prepare to talk with the
patient in private. There should be adequate seating for the patient,
the physician, and other family members.
Although preparation is important, communication doesnt have to
be very time consuming, she said. Physicians who work with an
interdisciplinary health care team may find it helpful to have a
social worker or nurse present. Once the physician confirms the
medical facts of the situation and answers questions, perhaps someone
else on the health care team can address other concerns of the
If a translator is needed, find one who understands medical terms and
is prepared to translate bad news, Dr. Zhu-kovsky said. Avoid using
family members as translators, she added, since an experienced
translator will give a more neutral presentation.
Begin by assessing what the patient already knows about the illness.
Start from where they are, not where you are, Dr.
Zhukovsky said. Determine how much the patient wants to know by
asking. The physician might say, Would you like me to tell you
the full details of your condition? or Do you want me to
go over the test results now and explain exactly what I think is wrong?
Try to be sensitive to cultural differences, Dr. Zhukovsky said. Such
cultural differences may inform the way patients and family members
respond to medical information. Americans, for instance, may accept
the diagnosis but struggle with the uncertainty of the prognosis.
Patients from other cultures may find it difficult to hear the
diagnosis. In some cultures, cancer is believed to be a consequence
of having done something wrong.
In many situations, the family will ask the physician to avoid
telling the patient the diagnosis. The family may believe that
sharing the diagnosis will take away the patients hope. In
other cases, family members who have had a difficult relationship
with the patient may feel guilty and unable to accept the
patients likely death. In both situations, the request not to
tell is an attempt to protect themselves and the patient from the
emotions that accompany a life-threatening illness, Dr. Zhukovsky said.
When faced with a family that says, Dont tell, the
physician should ask the family to express their concerns about
telling the patient. Ask family members what it is theyre
afraid of, Dr. Zhukovsky suggested. It may be appropriate for
the physician and family together to ask the patient how much he or
she wants to know.
A diagnosis of life-threatening illness need not take away hope.
Diagnosis often opens up opportunities rather than closing
them, Dr. Zhukovsky said. Patients facing cancer may use their
time to re-examine their lives, to resolve conflicts, complete
projects important to them, go on trips, or create a videotape for
children to remember them by.
The Horvitz Center for Palliative Medicine at the Cleveland Clinic
uses family conferences for its patients as a means of sharing
medical information and addressing the patients psychosocial
needs, she said. The advantage of this is that everyone gets the
information at the same time. Family members who live far away can be
included with a conference call.
When the patient is ready to hear the diagnosis, give the diagnosis
without euphemisms, Dr. Zhukovsky said. You want to be blunt
without being cruel, she said, but euphemisms can really
get you into trouble. She described meeting a patient who knew
he had had chemotherapy for his tumor, but didnt know he had
cancer. She said she uses the word cancer initially
during her diagnosis but then will soften her message by using the
Present the information in small chunks and respect the ability of
the patient to absorb the news, she said. Pause frequently and check
for understanding. Be prepared for a broad range of reactions.
Nonverbal communication and silence can be very helpful. Listen
quietly and attentively to the patients reaction, Dr.
Zhukovsky said. You learn more by not saying anything. With
silence, people will begin talking.
The phrase Im sorry should be adjusted to make it
clear that the physician is expressing empathy rather than apology or
pity. Im sorry to have to give you bad news is
better than simply saying Im sorry, she said.
If the patient asks for a prognosis, the physician should first
assess his or her reasons for asking and determine how specific the
prognosis needs to be. It is notoriously difficult to predict how
close a patient is to death, Dr. Zhukovsky said. She acknowledged
that even after caring for numerous patients who died, she is not
good at predicting. The EPEC program suggests responding with a range
of time, such as hours to days, days to weeks,
weeks to months, or months to years.
Physicians can prepare families who are praying for a miracle for
unexpected surprises, both good and bad, by presenting medical care
within the context of hoping for the best and planning for the
worst, Dr. Zhukovsky suggested.
Finally, establish a follow-up plan. Explain how the physician can be
reached to answer additional questions. Before the patient leaves,
make sure he or she is not too distraught to get home safely. If the
patient is alone, for example, Dr. Zhukovsky suggested asking,
Should we pick up the phone and have someone come get you?
The short video viewed by the group showed a scene in which a
physician confirms a diagnosis of adenocarcinoma in a patient who has
had a colonoscopy for a mass in the descending colon. The doctor
introduces the bad news by saying: I know you wanted it
straight. Other phrases used by the doctor include: Tell
me what youre afraid of, and Is there anyone else I
can talk to? The physician also offers emotional support by
offering to be there for the patient and by saying,
Were going to take this one step at a time.