Most physicians feel they lack this type of training

By Alistair Gardiner
Published February 1, 2021

Key Takeaways

Some days, it seems like the bad news keeps coming. As the COVID-19 pandemic progresses, physicians often find themselves delivering more difficult news to patients and their family members than they typically might. That is, after all, a byproduct of a pandemic that has killed nearly 450,000 US patients.

Breaking bad news can be emotionally taxing and stressful for any physician during the best of times—but it’s especially difficult during the pandemic, when families can’t be at their loved one's hospital bedside and are anxiously awaiting news at home.

One study, published in Baylor University Medical Center Proceedings, looked at the delivery of bad news to patients, and found that 93% of respondents believed delivering grim news is a very important skill, yet only 43% felt they had the right training to effectively do so. 

The need for this type of training has become abundantly clear during COVID, as described in an article last June in the Harvard Business Review. When New Jersey’s RWJBarnabas Health system became overwhelmed with COVID-19 cases, the organization piloted a “Goals of Care Conversation Team” at five of its hospitals to have difficult discussions with families of critically ill patients. A scripted conversation tool was developed to train team members, based on communication resources available online, including VitalTalk’s COVID Ready Communication Playbook and the Center to Advance Palliative Care’s COVID-19 Response Resources.  

And of course, COVID is not the only culprit behind all the bad news. Doctors are called to share difficult news with patients and families for other serious illnesses, terminal prognoses, disease recurrence, unexpected clinical findings, and more.    

While there may not be one definitive roadmap for delivering difficult news, there are resources that doctors can turn to. With that in mind, here are four tips to help guide the process of delivering bad news, based on studies and strategic systems developed over the years.

Be prepared

The first step occurs before a physician even enters the room—or virtual room, as the case may be—with their patient or family members: preparation. This is the first tenet of two widely adopted models of guidance for delivering bad news, the ABCDE and SPIKES models. 

The ABCDE system, first laid out in an article published in American Family Physician in 2001, is still widely used in medicine today.  

Physicians can best prepare by reviewing all relevant clinical information and mentally rehearsing the conversation, according to the ABCDE system. This process includes identifying useful and must-avoid words and phrases. It’s also important to ensure that a patient or family member has enough time to process the news, and that the appointment occurs in a private, comfortable location, with no interruptions. Finally, physicians can expect and prepare for emotional responses from the patients, family members, and maybe even themselves.

The SPIKES model for delivering bad news, originally published in The Oncologist in 2000 as a protocol for delivering bad news to cancer patients, is still commonly used today by clinicians seeking to communicate with patients in a clear and supportive way. 

The SPIKES model suggests including a significant other, like a family or friend, in the conversation who can help comfort the patient. It also recommends making a connection with the patient through eye contact during the conversation—a talk that will most likely take place in a virtual meeting in today’s environment—and letting the patient know the doctor is not in a rush. 

Studies support the efficacy of these techniques. The authors of a 2019 review of curricula for empathy and compassion training in medical education, published in PLoS One, examined 52 studies and found five key behaviors to be effective at conveying empathy and/or compassion: 1) Sitting down during the conversation; 2) Recognizing patients’ nonverbal cues of emotion; 3) Seeking out and responding to opportunities for compassion; 4) Employing nonverbal communication to demonstrate caring (eg, eye contact); and 5) Using statements that are acknowledging, validating, and supportive.  

Build relationships

Another important aspect of the ABCDE and SPIKES models involves building a therapeutic relationship and environment.

Physicians are advised to preface a difficult conversation by informing the patient that bad news is coming. Doctors can communicate with the patient to understand precisely how much detail the patient wants, wrote the authors of the article in The Oncologist. That way, the conversation can be tailored to provide the necessary information in the most compassionate way.

This is vital, as a patient might not be willing or even able to hear every detail of the news. Some patients actively ignore certain pieces of information as a coping mechanism. It’s equally useful for the clinician’s mental health; getting a patient’s explicit consent to receive information can lessen the anxiety tied to delivering bad news.

If a patient prefers less information, a doctor can:  

  • Assure the patient of their availability

  • Offer to answer any questions in the future

  • Give greater detail to a family member or friend who’s in the room

It’s key to read the patient’s body language and other emotional cues, while adopting the language and pace that’s appropriate to the patient’s level of understanding.

Be straightforward

It’s essential to be frank and compassionate when delivering bad news to patients or their loved ones. They should be given a chance to react to the news, absorb the information, mirror back their understanding, and ask questions.  

It’s also important to provide a timeline of events and to clarify any uncertainty in the prognosis. Avoid medical jargon or euphemisms and language that’s too blunt or dispassionate.

Before explaining possible treatment options, make sure the patient is ready to have that discussion, conveying that their desires are important. From a physician’s point of view, sharing responsibility for decision-making can reduce any sense of failure should the treatment prove unsuccessful. Physicians want to be clear when discussing treatments, so the patient or loved one understands the purpose and/or efficacy of the treatment options.

Employ empathy

Perhaps the most important and often-cited element of all strategies for delivering bad news is empathy. When patients or family members receive bad news, their reaction can range from shock to grief. To exhibit empathy, physicians can:

  • Acknowledge the emotion by asking the patient open questions regarding their thoughts and feelings

  • Identify the reason for the emotion, which may not be entirely due to the bad news they just received

  • Provide time and space for the patient to express their emotions

It’s important to wait until the emotion has subsided before moving on with the discussion. Empathic responses, like the clinician expressing their own feelings of sadness regarding the news, can sometimes help to validate a patient or loved one’s feelings.

Studies have found that patient perception of their doctor’s compassion might even affect patient health outcomes. One 2019 study, published in Intensive Care Medicine, found that the more compassion that emergency department patients sense in their healthcare providers, the lower their risk of developing post-traumatic stress disorder after discharge.  On the other side of the coin, studies have also turned up evidence that compassion can enhance a physician’s resilience and resistance to burnout.

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