Feb 21, 2012
By Giao Q. Phan, MD
Bad news is any news that negatively affects a person’s view of their future.1 Physician or not, everyone dreads giving bad news. We worry about causing anxiety and stress to another person. Empathy causes us to feel distress when we see others distressed.
For someone who takes care of patients with cancer, breaking bad news becomes, at times, a daily event. The way we tell bad news to patients can affect their perception of their illness.2 Thus, in the process of conveying bad news, we should aim to help patients understand their illness and prepare for the future, address their fears and anxieties, provide therapeutic and/or palliative options, and offer emotional support.
While some oncologists may have had formal training, most of us learn how to give bad news on the job. I learned the most about this process during my immunotherapy fellowship at the National Cancer Institute, during which I mainly took care of patients with stage IV melanoma treated in immunotherapy protocols. Even during the best weeks, we always had to tell someone that the experimental treatment did not work and that their tumor was growing.
How to give bad news was one of the most valuable skills I learned that year. Dr. Steven Rosenberg of NCI, my mentor, consistently emphasized that while we must be honest and direct, we must not take away a patient’s hope; he always made sure to bring out an encouraging point in the patient’s situation, be it how he or she was still asymptomatic, that there were other treatment options available, or that there were methods that could take away pain and ease suffering even in the patient’s last days.
Now that I have been an attending physician for a few years, I really value this simple but critical advice. Research has shown that disclosure of cancer diagnosis and other “bad news” does not necessarily take away a patient’s hope. In fact, providing thorough information in a supportive way can help alleviate patient anxiety and stress.3-7 Several consensus guidelines, which encompass similar principles, have addressed how to communicate bad news to patients.8-10
Based on these guidelines and my own experience, I would like to share eight tips for delivering bad news in a compassionate way:
1. Provide a quiet, private place and uninterrupted time. Make sure that both you and the patient are sitting down to demonstrate that you are not in a hurry.
2. Assess the patient’s understanding of the situation. The information you need to provide will depend on how much awareness the person has of his or her disease status.
3. Give information clearly and honestly; avoid excessive medical terms and euphemisms. Sometimes it is difficult for patients to accept or understand their situation, so relevant facts may need to be repeated.
4. If the discussion involves disclosure of tumor progression or recurrence after a treatment, it is crucial to articulate that the treatment failed rather than the patient failed the treatment. Saying that the patient failed the therapy is a subtle error that may make patients subconsciously feel that they did something wrong.
5. Acknowledge the patient’s reactions and responses. Let them know that their feelings, be it anger, sadness, fear, or disbelief, are normal and understandable. Express sympathy and offer reassurance through eye contact, body language, and words.
6. Offer what you can do to help—a critical step to provide patients with hope even after the grimmest disclosure. This may involve discussing available treatment options and referral to clinical trials, recommending pain alleviation methods and other means of symptomatic relief if and when needed, offering to help break the news with the patient’s loved ones, and providing contacts to other supportive resources such as social workers and palliative care services if appropriate.
7. Many patients will ask, “How much time do I have left?” While it is important to be direct, it is also important to clarify that no one is a fortune-teller. Median survival is just that—a median, a statistic. I find that explaining median survival is helpful for the patient and generally will say, “For someone in your situation, median survival is X-time, which means that of 100 people, 50 will live less than X-time and 50 will live more than X-time.” In this way, you present a timeframe that is broad but realistic enough to allow the patient to prioritize his or her personal affairs.
8. Offer to meet again soon after to re-discuss anything that may be unclear or address new questions that the patient will invariably have. At the very least, a follow-up phone call soon after can be very helpful for the patient.
Patients entrust us with their health and their hopes, and when we have to convey bad news regarding their health, we must ensure that they are given thorough, honest information while not demolishing their spirits.
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2. Omne-Ponten M, Holmberg L, Sjödén PO. J Clin Oncol. 1994;12:1778-82.
3. Molleman E, Krabbendam PJ, Annyas AA, et al. Soc Sci Med. 1984;18:475-80.
4. Parker PA, Baile WF, de Moor C, et al. J Clin Oncol. 2001;19:2049-56.
5. Sardell AN, Trierweiler SJ. Cancer. 1993;72:3355-65.
6. Smith TJ, Dow LA, Virago E, et al. Oncology (Williston Park). 2010;24:521-5.
7. Brown VA, Parker PA, Furber L, et al. Eur J Cancer Care (Engl). 2011;20:56-61.
8. Girgis A, Sanson-Fisher RW. J Clin Oncol. 1995;13:2449-56.
9. Girgis A, Sanson-Fisher RW. Behav Med. 1998;24:53-9.
10. Ellis PM, Tattersall MH. Ann Med. 1999;31:336-41.
Giao Q. Phan, MD
Member since: 2001
Specialties: Surgical oncology, endocrine surgery, immunotherapy
Institution: National Cancer Institute
Education: Medical degree, Johns Hopkins University School of Medicine; residency, Washington University in St. Louis; fellowships, National Cancer Institute and Moffitt Cancer Center
ASCO activity: Member, Career Development Subcommittee (2009-2012)