How Doctors Break Bad News

There is no formula for telling a patient that he or she has cancer. The diagnosis is still perceived, for the most part, as a death sentence, and a patient’s reaction is usually a combination of fear, despair, and anger. How a physician delivers the news about the diagnosis, however, and his or her empathy for the patient’s situation have a profound effect on the patient’s emotional well-being. This commentary, adapted from an article that appeared in InTouch (June/July 1999), describes the anguish surrounding both the bearer and receiver of “bad news.”

One March morning in 1994, Linda Rhodes sat in her fifth-floor office in Houston, Texas. She was catching up on some paperwork when the telephone rang. It was her doctor, whom she had been trying to reach for days to get the results of a bone scan taken a week earlier.

“Linda,” the physician said, “it looks like the cancer is in your spine,” referring to the spread of breast cancer Rhodes thought she had beaten 2 years earlier. She was devastated. The cancer had returned, this time to her bones, and she knew the prognosis was poor. Her first thought was that she would die fairly soon. “There’s nothing more we can do for you at this hospital,” the doctor said abruptly, and the conversation ended.

Rhodes, an optometrist with a busy private practice, instructed her secretary to cancel all her appointments for the next 2 weeks. Too distraught to drive home, she called her 19-year-old son for a ride. As a 45-year-old single mother, her mind raced with questions: Who will take care of her children? What will happen to her house? What will she do with her practice? What next?

Two weeks later, Rhodes went to see another doctor, who informed her that her medical tests had been misinterpreted. The area diagnosed as a tumor was actually a herniated disc and slightly fractured vertebrae caused by a jet ski accident several months earlier. The fracture never bothered her and required no treatment. “When I got the news, I felt like somebody waved a magic wand over me,” she said. Still, “all those moments [when she received the bad news] are frozen in my memory,” she added.

A Study in Contrasts

Studies show that the way a doctor delivers bad news stamps an indelible mark on the patient-doctor relationship, in some cases even prompting lawsuits. Like a hit-and-run driver, Dr. Rhodes’s physician knocked her flat with bad news, didn’t stop to see how she took it, and fled the scene. That memory lingers in sharp contrast to the first time a doctor told her she had breast cancer, 2 years earlier.

“I went in for a breast biopsy, and I was in the recovery room,” she recalls. Her doctor sat down on her bed, looked her in the eyes, and told her that her biopsy indicated breast cancer. “He touched my shoulder and let me cry for a while before he started outlining a treatment plan for me,” she said. “By the time I left half an hour later, I had a plan that gave me hope that something could be done.”

In her later experience, Rhodes learned first-hand that when a doctor delivers bad news over the phone and doesn’t allow time for a person to react, or neglects to say what will happen next, the news can be devastating.

However, most medical schools don’t offer students any formal instruction in breaking bad news, and physicians often have to devise their own method.

Surveys have shown that doctors rank discussing a recurrence of cancer with patients as one of the most difficult tasks they perform. Telling a patient that he or she has cancer for the first time is easier for most doctors because they can usually offer hope in the form of treatment options.

Oncologists, some of whom have to break bad news as often as 20 times a month, often feel unprepared to deal with the emotional demands of such sessions. A patient may break down in tears or turn hostile. Without training or guidance from a peer, even the most empathetic doctor will find this tough to handle. So they often adopt an air of aloofness, and that hampers good communication, said Walter Baile, MD, chief of psychiatry at The University of Texas M. D. Anderson Cancer Center in Houston.

“Doctors are taught that in order to apply their technical expertise, they have to be detached emotionally, but patients may experience this aloofness as insensitivity,” he said.

Dr. Baile and his colleague Robert Buckman, MD, an oncologist at the University of Toronto, have developed a program doctors can follow when breaking bad news.

Effective Listening: An Oft-Overlooked Technique

Some of the techniques that Drs. Baile and Buckman outline are common sense: talking face-to-face in a private room rather than over the telephone, discussing treatment options in language that a layperson can understand, and answering all the patient’s questions. However, one of the most important techniques—effective listening—is often overlooked.

Studies have shown that in an average office visit, patients talk a mere 18 seconds before their physician interrupts them. Less than a quarter of patients even get to finish their opening statements.

Part of the problem is that listening takes time—a precious commodity for most doctors. But given that listening plays a critical role in helping a patient digest bad news, failure to do so can derail even the most well-meaning attempts to relay bad news gently.

Tips From a Physician Cancer Survivor

Jane Poulson, md, a practicing internist at the Toronto/Princess Margaret Hospital, also teaches communication skills to medical students at the University of Toronto. Her own diagnosis of breast cancer in 1996 and the emotional roller coaster ride that followed came as a rude awakening. “I realized the number of bitter pills I had unwittingly delivered to patients during my 15 years of practice,” she recalled. Dr. Poulson wrote about her experience in the Journal of the American Medical Association (338[25]:1844-1846, 1998).

Whenever Dr. Poulson had to break bad news to patients, she tried to buoy them with reports of how much less mutilating breast surgery had become, or how some new technology had made for better colostomies. Few patients seemed encouraged by this kind of information, but it made Dr. Poulson feel better to tell them “some good things about the procedures.”

However, her own experience as a patient taught her that “if I were to do it again, I wouldn’t rush in with the ‘good news.’” When people suffer the initial shock of a cancer diagnosis, “they need to vent their fears or anger,” Dr. Poulson observed, and a doctor should resist the temptation to staunch the flow of their feelings. “It’s hard to knock someone down and resuscitate them in the same sentence,” she said.

A better strategy is for the doctor to say something like “This must be difficult for you,” thus opening the door for a patient to express his or her feelings. Drs. Baile and Buckman advise physicians to first ask a patient what he or she knows about the situation; then deliver the news in small chunks and simple language; and then acknowledge the strong emotions that follow. They caution doctors not to interrupt, rather they should make eye contact, and repeat key points.

‘Don’t Worry’ and Other Platitudes

Dr. Poulson acknowledged that before she began losing her own hair during chemotherapy treatments, she had no idea how awful it felt. She used to reassure her patients that their hair would grow back, but she didn’t realize that “hair loss is symbolic of all that happens to your body when you have cancer. Telling a person, ‘don’t worry, your hair will grow back,’ doesn’t really address the problem of the despair they’re feeling about what is happening.”

Sometimes, an off-hand comment early on makes breaking bad news later more difficult. When Christine Perry, a newsletter editor in Boston, was told that she needed a biopsy on a small growth on her lip, she asked her doctor if the growth might be cancerous. “You’re 30 years old, don’t worry about it,” her doctor responded while moving toward the door. “If it’s cancerous, you’d have surgery, but just don’t worry about it.”

Ms. Perry wanted to probe more, but “felt like I was taking up too much of her time by asking questions.”

Several days later, she found out that the growth was, in fact, cancerous. Ms. Perry’s doctor had an assistant telephone her at work to break the bad news.

Hearing the news over the phone left Perry shaken and tearful from fear and frustration.

“I know that the doctor was probably just trying to make me feel better before the biopsy,” said Ms. Perry, but the doctor’s failure to address her concerns before she received the bad news made absorbing it later that much more difficult.

Phrases to Avoid

Another thing some doctors may unwittingly do when delivering bad news is use phrases like “there’s nothing more we can do for you.” Even when they’ve exhausted all treatment options, doctors can still help patients “die with comfort and dignity,” said Michael Levy, MD, head of the Supportive Oncology Program at Fox Chase Cancer Center in Philadelphia. Dr. Levy recommends that doctors explain that in some cases continuing treatment does more harm than good, and that pain management and other strategies can relieve a patient’s discomfort at the end of life.

He also suggests that physicians should never say “we got it all” after a course of treatment. This sort of pronouncement implies that the patient has been cured of cancer—an overstatement that can come back to haunt both the patient and doctor if the disease recurs. A better phrase would be “we got everything we could see at this time,” offers Dr. Levy.