How to Deliver a Terminal Diagnosis to Patients: A Helpful Approach

Death is an inevitable part of life. Consequently, many physicians are faced with the difficult task of conveying news about a terminal illness to their patients. Some physicians feel inadequately prepared for this task while other physicians fear that conveying this distressing news will adversely affect the patient-physician relationship and cause the patient emotional distress. While experience is arguably the best way to learn how to break bad news, some physicians and many medical students have limited experiences in working with terminally ill patients.

There are, however, some helpful suggestions that physicians and medical students can use to effectively prepare for this event. The Project to Educate Physicians on End-of-life Care¹ (EPEC) offers a 6-step approach (adapted from How to Break Bad News: A Guide for Health Care Professionals by Robert Buckman) that physicians can use to communicate bad news in a "direct and compassionate way [that] can improve the patient’s and family’s ability to plan and cope, encourage realistic goals and autonomy, support the patient emotionally, strengthen the physician-patient relationship, and foster collaboration among the patient, family, physicians, and other professionals." (Module 2, p3)

The first step of the approach is to plan what you will say to the patient. It is important not only to confirm the diagnosis and lab results, but to also speak to relevant specialists about future plans before presenting information to the patient. There is nothing worse than relaying false information to patients, especially information pertaining to a life-threatening illness that can potentially cause the patient emotional distress. Determine whom else the patient would like to have present at the meeting and schedule extra time in order to answer any questions or concerns that the patient or family members may have regarding the diagnosis or future plans.

In the second step, determine what the patient knows about his or her illness. This can be done by asking the patient about what he or she understands about the illness or what other physicians have told the patient about the illness. Having this knowledge will not only help the physician focus the discussion on those topics that the patient does not know about, but this information will also help the physician determine if the patient and family members will be able to comprehend the new information.

Thirdly, find out about how much the patient wants to know about the diagnosis since people handle information differently, based on their race, culture, ethnicity, religion, and socioeconomic class. This can be done by asking the patient and family how they would like to receive the information and whether he or she would like to review the test results. Patients have the right to refuse treatment; in the same way, patients having adequate decisional capacity may choose not to receive any new information regarding the terminal diagnosis and may designate someone else to communicate on the patient’s behalf. For example, some patients prefer not to be told about their terminal diagnosis. In this case, the patient should identify someone who will receive this information on behalf of the patient. In other cases, the family members will inform the physician not to tell the patient about the diagnosis. While the physician is legally bound to obtain informed consent from the patient, the physician should determine why the family is hesitant to disclose the bad news to the patient. Situations like these present a special and complex ethical dilemma and so physicians may consider consulting an ethics committee in order to derive a plan that is morally acceptable to the patient, patient’s family, and physician.

The first three steps set the stage for the fourth step, which is delivering the bad news. The physician should ensure that the meeting is held in privacy. The physician should either turn off his other pager or give it to a colleague and should answer any calls at a more appropriate time. This will ensure that the physician’s attention is directly focused on the needs of the patient and family members. When sharing information, the physicians should be seated close to the patient and preferably at the same height as the patient. In addition the physician should use simple terms and language that is easy to understand. Even though it may be simply stated, news of a life-threatening illness can be distressing and overwhelming for the patient and family members. In order to help the patient and family members process the information and deal with the emotional distress, the physician should pause frequently and encourage the patient and family members to ask questions or clarify details. One way to do this is to periodically pause for 20 seconds in order to give the patient or family members time to process the information, ask questions, or address any concerns.

The fifth step is to respond to the patient and family members’ feelings. Patients and family members can react to the bad news in many ways, ranging from denial to anger, anxiety, and fear. In these emotionally charged situations, it is important that the physician acknowledge the patient’s fears and concerns, something that can be accomplished by listening actively and compassionately. Also, encouraging the patient to share their feelings may help the patient develop trust in the physician, thereby ensuring a stronger patient-physician relationship. Often, using non-verbal communication can ease the anxiety and reassure the patient that he or she is not alone in this process.

This reassurance leads to the last step in this 6-step process, planning and follow-up. During the meeting, the physician should explain future plans and any tests that will be done. The physician should also discuss potential sources of emotional or supplemental support and, if necessary, make a referral to hospice. It would be beneficial to both patient and physician if this process of disclosure and planning were to take place during multiple visits or meetings since many patients and family members require repetition of the news in order to completely understand the situation.

Dr. Steven Rothschild, Associate Professor in the Department of Family Medicine at Rush Medical College, recommends that physicians make three commitments to their patients. First, the physician should assure the patient that every effort will be made to treat and relieve the patient’s pain and other symptoms, especially near the end of the patient’s life. Secondly, the physician should reassure the patient that the physician will not abandon the patient in the future, but will, rather, be involved in every step of the caring process. Lastly, the physician should confirm his or her role as the patient’s advocate and that the physician will support and honor any decisions that patient and family makes in regards to the patient’s care.

These three commitments along with the approach outlined above is one method that current and future physicians and medical students can use in preparing to convey bad news to patient. Even though the 6-step approach seems obvious or simplistic, physicians tend to forget the basics and focus on the difficult task of diagnosis when preparing to deliver bad news to the patient and family. The way that the physician relays bad news to the patient can determine everything that happens in the future and so it is important to plan well. The focus of this process should be on the patient’s welfare since the "secret of the care of the patient is caring for the patient...the good physician knows his patient through and through"²

Resources

1. American Medical Association Institute for Ethics. Education for Physicians on End-of-life Care (EPEC) Participant's Handbook. Chicago: American Medical Association; 1999. Supported by a grant from the Robert Wood Johnson Foundation.
2. Peabody, F.W. The Care of the Patient. The Journal of American Medical Association.1927; 88: 877-882.
3. Buckman, R. How to Break Bad News: A Guide for Health Care Professionals. Baltimore,MD: The Johns Hopkins University Press; 1992: 65-97.
4. Cassel, C.K., et. Al. Caring for the Dying: Identification and Promotion of Physician Competency. American Board of Internal Medicine, 1996.
5. Quill, T.E., Townsend, P. Bad News: Delivery, Dialogue, and Dilemmas. Archives of Internal Medicine. 1991; 151: 463-468.