Recurrence. Transformation. Progression. Second malignancies. Non-malignant late effects. Oncology is a field where even on good days you give bad news to at least some of your patients.
I don't envy you this thankless task. Those of you who do it well receive little praise from patients, your tenderness overshadowed by the facts of their disease or disability. And we all know what happens if patients perceive your delivery of bad news as brusque: Some will broadcast reports of your alleged callousness as fast and far as telephone lines and cyberspace can carry them.
Breaking bad news to patients is tough. You have to explain how their situation is what they feared. As if this wasn't challenging enough, you have to do it while fulfilling two obligations that seem mutually exclusive: telling the truth and nourishing patients' hope.
Over the years, I've collected a few “bad news” pearls from wise oncologists who found words that prepare patients, plant seeds of hope, bolster patients' confidence, and offer comfort.
You may already be using at least some of these pearls in your practice. Still, it is worth taking a moment to reflect on the power of your words to help patients heal after learning bad news.
If physicians are going to deliver bad news without any warning, they might as well punch their patients in the gut or push them into the deep end of a pool from behind. Patients silently gasping for air can't pay attention to anything else their physicians say, let alone process or remember the information. Often in these cases, the verbal blow leaves a stinging memory, recalled in vivid detail forever after.
So the first task is finding words to warn your patients, alerting them without alarming them. If said calmly, any of the following expressions fit the bill:
- I wish I had better news for you today.
- This is not the news I was hoping to give you.
- This is going to be difficult for me to say and, I expect, difficult for you to hear.
Such introductions hint at your own distress, and that's more than okay. It tells patients they matter to you. Keep in mind that sharing your feelings is healing if—and only if—expressed in the composed tones of uncompromised competence, for this is the quality patients seek in you and need more than any other.
By definition, bad news crushes patients' hopes. Naturally patients then look to you for signs—Is there any hope for me?—and guidance—What should I hope for now?
For patients whose long-term prognosis remains good, your words can put a tourniquet on hemorrhaging hopes. Start by putting boundaries around what has been lost, taking care to avoid the subliminal suggestion of patient responsibility associated with phrases such as “since you are allergic to this treatment…” or “since you failed your treatment….” Then link the hope that has been dashed with the promise of new hope:
- Since this treatment caused an allergic reaction, we'll stop it and use another good treatment.”
- Although this remission didn't last as long as we'd like, we still have good treatment options.”
- Since this regimen stopped working, we'll switch to another that works differently.
When you mention available treatment options, don't assume your patients will automatically know to have hope. Be direct:
- It is not time to give up hope of recovery.
- You have good reason to feel hopeful about recovery.
- It may be a rough road, but I have hope for your recovery.
- I know (many) patients in remission who went through what you are going through now.
You can't underestimate the power of your words on patients. Unlike the fervent expressions of hopefulness offered by loving friends and family, your explanations and reassurances are based on medical expertise and experience. In addition, patients know you have a professional duty to tell the truth about what is likely to happen based on statistics.
In cases where you've exhausted all treatment options, reassure your patients: I'm leaving no stone unturned. Let them know if you've consulted with colleagues, reviewed the literature again, or recently attended a conference about treating patients with their disease.
You can crack open the door to hope by focusing on the uncertainty. After telling patients what usually happens in situations such as theirs, you can add: Occasionally things happen in medicine that we don't expect and can't explain. I hope my prognosis is wrong and your condition improves.
You can push open the door a bit wider by reminding patients of the hope of research. This is not an empty offering. I will never forget the surge of hopefulness I felt when the researcher at Stanford who had treated me in a clinical trial said off-handedly, I'm always looking for something new that might help you.
When your patients are knocked down by bad news, offer them a hand up by expressing confidence in their ability to handle whatever lies ahead.
- You've gotten through treatment before. You can get through treatment again.
- I've seen what you are made of. I believe you can do this.
Whatever the news or the circumstances, you can comfort patients with the promise of bringing the tools of modern medicine to manage any pain. If nothing else, you can reassure patients of the one thing in life you can guarantee: You don't have to do this alone. I'll be by your side, whatever happens.