As a physician, you will have to deliver bad news to your patients. It’s a reality of the profession. How you present such news—how you communicate it to your patient and allow them to process it—can affect a patient’s outlook on their situation.
Few people are as well versed in telling patients news they may not want to hear as Steven Pantilat, MD, a professor of medicine at the University of California, San Francisco (UCSF) School of Medicine and the inaugural chief of UCSF’s palliative medicine division.
A pioneer in the field of palliative care, Dr. Pantilat estimates that he has cared for thousands of people who have received “really bad news.” In a recent presentation at TEDMED 2018—the annual health and medicine edition of the world-renowned TED Talks—he compared the startling feeling patients experience when they receive a life-altering diagnosis to the feeling a passenger on a plane may feel if the plane begins to take a sudden nose dive.
“While it feels like [a patient] is going to die, it turns out there’s a lot we can do to right the plane and get it to fly smoothly,” he said.
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Back at TEDMED, Dr. Pantilat offered these tips that medical students and residents should heed as they learn, by practice, the difficult art of delivering bad news.
Understand the gravity of the news. “The first thing in delivering bad news is recognizing what bad news is,” he said. “Which is to say that sometimes we are delivering bad news and not really recognizing that we are delivering bad news. …Be thoughtful about that. A lot of women might have a mammogram and be asked to take another view. Well, that’s not good news, and I think sometimes we don’t recognize that that’s bad news and that needs to be prepared for.”
Prepare the patient for what you are about to say. “Say [something like], ‘I’m sorry to have to tell you this, but the biopsy shows that it’s cancer’—and then just be quiet,” Dr. Pantilat said. “The tendency is to want to keep talking because everybody is uncomfortable and the patient is in shock. But because the patient is in shock, it’s very hard to hear or remember anything else.
“For the patient I always think it’s like when the adults talk on Charlie Brown … and the patient can’t hear anything. So just wait. Let the patient have their reaction. It may be a time where you can give more information and it may not be.
“The other thing is you [and your patient should] anticipate bad news. So for example if you order a test that could result in bad news—you send someone who might have a diagnosis of ALS [amyotrophic lateral sclerosis] for a nerve study, for example. Just let them know this is why I’m ordering this test and if the results come back a certain way, this is what it could mean so that people are prepared for it.”
Have a plan. “Earlier in my career, when I did more primary care, it was right in the middle of the AIDS crisis,” he said. “I think about giving an HIV test. What was my plan going to be for giving someone that news if the result came back positive? You have to have a plan.”
“Where do we go next? [A physician has] to be able to provide support for the patient, to let them know that I’ll be with you through this and here’s the plan … to make sure that there is contact and a way forward together.”
Be honest. When a patient receives bad news, their first question may be, “Am I going to die?” As a physician, Dr. Pantilat said, you may not know the answer.
“That’s really challenging, particularly at the very beginning [of a diagnosis], when you may not know,” Dr. Pantilat said. “For some illnesses we do know. ALS, for example, if you make that diagnosis you know the eventual outcome, though it may be years down the road. The question is a good one because it reminds us that is what people are thinking, that’s really their first thought when they get a serious diagnosis. It’s almost like trying to pull people back and then they think, ‘OK. I’m going die, but now, how am I going to live?’
“If it’s very serious and advanced illness, I do my best to answer honestly. I might say something like, ‘This is a really serious illness. I can see why you’d be thinking about that. We’re going to do everything we can to help treat this illness and see how it goes.’ Acknowledging that and not giving false reassurance is important,” he added. “And yet I find that the moment of diagnosis is not the best time to start delving into those questions. Because you often don’t know what the prognosis is going to be.”
The AMA Code of Medical Ethics offers guidance on caring for patients at the end of life to help you discover how advance-care planning can give patients peace of mind knowing that their physicians understand their wishes for care at the end of life.