How to Address Monumental Patient Conversations

Photo by Steve Fisch.

At some point, every physician will need to share difficult news with a patient. Although these heartbreaking moments are unavoidable in the practice of medicine, there is little formal education on how to navigate these encounters. What is clear, however, is that a physician’s words and bedside manner can impact how patients process the information. Compassion, empathy and comfort are important pillars of strength for patients, particularly in dark times.

 The American Medical Association’s code of medical ethics (published in 1847) underscored the emotional impact of a physician: “The life of a sick person can be shortened not only by the acts, but also by the words or the manner of a physician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have a tendency to discourage the patient and to depress his spirits.” Since that statement was first printed, the practice of medicine has significantly evolved, but the importance of the physician’s words and manner still rings true.

In an article published by American Family Physician, Michigan State University’s Gregg K. Vandekieft, MD, explains that modern medical training places greater value on technical proficiency rather than communication skills. “Therefore, physicians may feel unprepared for the intensity of breaking bad news, or they may unjustifiably feel that they have failed the patient,” he writes.

To better equip physicians with these skills, Vandekieft cites the following guidance from University of California San Francisco’s Michael Rabow, M.D., and Stephen McPhee, M.D.

The mnemonic “ABCDE” can help physicians break bad news:

1.     Advance Preparation

Prepare for the conversation by scheduling adequate time and removing distractions. Remember to review relevant clinical information, mentally rehearse the conversation and make sure you’re emotionally prepared.

2.     Build a Therapeutic Relationship

Determine what information the patient needs and be prepared to interact with their family or other emotional supports. Introduce yourself to everyone in the room and warn them that there is difficult news to share. After the conversation, schedule follow-up appointments.

3.     Communicate Well

Seek to understand the patient and family’s existing knowledge. Be clear and compassionate in your delivery by avoiding euphemisms and jargon. Speak in plain language. Build in time for the patient to process the information—whether that is through silence, tears or questions. End the visit with a summary and follow-up plan. Provide written information when possible.

4.     Deal with Patient and Family Interactions

Be sensitive to the emotional needs to the patient and family and aim to be empathetic.

5.     Encourage and Validate Emotions

Seek to understand what the news means to the patient. If possible, offer “realistic hope” that is in line with the patient’s goals. Refer them to outside resources, if necessary. Remember to also examine your own emotional state and that of others who are involved with the case.

In an American Academy of Ophthalmology article, Ivan R. Schwab, M.D., of University of California Davis, emphasizes the importance of empathy when delivering bad news. “Your most important tools are your own feel­ings,” he explains. “Bad news comes to us all at some point, and if you deliver news to a patient using your own feelings, you will be a powerful support.”

University of Toronto’s Rosa Braga-Mele, M.D., adds that it is critical to be upfront with facts while still providing hope, if possible. “The most serious mistakes in delivering bad news may be simply avoiding it altogether or not fully relaying the severity of the situation,” she says. “We naturally feel sorry for the patient in this moment and want to give them hope. Hope is good, of course—but only in the context of remaining truthful and realistic so that, moving forward, the correct care and support systems can be set up.”

At Stanford we've also explored the importance of difficult conversations.  The Serious Illness Care Program, for example, is another resource for physicians hoping to learn how best to facilitate these moments.  We hope that any and all of these resources can help guide physicians through the process and help everyone, physician and patient alike, navigate these discussions.

For more information about the Stanford Serious Illness Care program, please click here.

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