Making bad news bearable

By Luke Anami

Tact and decorum is needed when one has to deliver potentially devastating news. At one time or another we have to be the bearer of bad news, more so the doctors who deal with the issues of life on a daily basis.

Bad news, especially that involves a loss of life, is particularly difficult to deliver as it can pierce the soul.

The situation is trickier given the fact that they may have had little or no opportunity to gain the skills needed to do this in a more sensitive and professional manner.

It is more difficult in Kenya as most medical schools lack courses on the subject. There are no courses called, "How to tell a patient she or he has cancer", "How to tell a father his child has died" or "How to tell a pregnant woman she is HIV positive".

Doctors may also feel ill-prepared to deal with the patient’s reaction to the news, which can range from anger to guilt and may even include blaming the bearer of the news for the current predicament.

A visiting American physician recently shared with Kenyan doctors and nurses on how to break bad news to a patient and their closest family member.

Often there are two scenarios — would it be better to tell the worst at the onset of the discussion or gradually build up to the worst?

The ‘D’ word

"Bringing out the "D" word when a loved one is suffering from a terminal illness is always a difficult thing to do, not only for physicians but ordinary people as well," Dr Tom Smith, the medical director of Thomas Palliative care Unit at Massey Cancer Centre, USA, says.

More so it is always difficult to break the news to family and friends, especially children. Therefore, giving bad news to patients is a special talent something no amount of education can teach, he adds.

But first, what is bad news? While this question may seem obvious, it is important to keep in mind that what a doctor feels is ‘bad news’ may not match what the patient feels is ‘bad news’ and vice versa.

So one should start by disclosing complete information about the diagnosis, prognosis and treatment of the illness the patient is suffering from. Smith says doctors often tell patients that they have chronic diseases such as cancer, hypertension, diabetes or HIV/Aids just like that. These illnesses are so commonplace in the medical field that the doctor may forget that they are ‘bad news’ to some patients.

More affected than patients

"Some doctors are ill prepared to give bad news and sometimes are even more affected than the patients when breaking news of a terminal illness. More often they have to learn to overcome their own emotions," Smith says.

While there are many recognised approaches to giving bad news. The goal is to enable the medical practitioners fulfil the four most important objectives of the interview disclosing bad news, which involves gathering information from the patient and transmitting the medical information.

Not everyone can be cured

And also providing support to the patient, and eliciting the patient’s collaboration in developing a strategy or treatment plan for the future.

While most terminally ill patients hope to be cured someday, not everyone can be cured.

"Every time you tell someone about what cannot be treated, patients always ask questions such as: Why me? Why my child?; What did I do to deserve all this? You can’t let me die, can you doctor?"

Before breaking the news, find out what the patient and his or her family know. "Don’t make any assumptions before you tell the bad news," he explained.

He explained: Before presenting bad news, especially to family members, consider providing a brief overview of the patient’s course of treatment to give everyone a common source of information.

Handled with care

Find out what the patient wants to know. What he already knows. Your language, demeanour, body language and tone of your voice are powerful communication tools that must be controlled and handled with care.

"Speak slowly, deliberately and clearly. Provide information in small chunks. Use basic language. Give the patient a written copy of the information you have discussed. Check reception frequently."

Does talking about death cause it to happen?

"Hiding your head in the sand is not the appropriate response, unless you’re an ostrich. If you don’t talk about death, you miss out on opportunities. For instance by avoiding the ‘D’ word, one may fail to make peace with their families and their creator," Smith says.

"For example, a cancer patient where I work, who understood his situation had time to pass learned lessons to his children in time,"

Delivering sad news

He advised medics to establish the patient’s culture as it can assist in delivering sad news such as death. "For instance, cultural practices affect how different people in the world break sad news. For example, in Japan, people do not talk about death," he said. Give fair warning, for example, ‘I am afraid I have some bad news’ then pause for a moment.

Although one may present bad news in a succinct and direct manner, Smith warns the medic to be prepared to repeat information and present additional information in response to patient and family needs. But first determine who among the family members should be present during the discussion.

"Sit quietly. Allow the news to sink in. Stop frequently to let the patient and his family to absorb process and ask questions. Wait for the patient to respond. Use silence effectively.

Listen carefully and acknowledge patient’s and family’s emotions. Ask ‘how are you coping with this news?’ Do not overwhelm with detail."