Conveying Bad News

by Robert S. Stall MD

    A basic philosophy of my medical practice is to keep patients informed each step of the way.  I openly discuss my thoughts after a physical assessment, what I am looking for when I recommend tests, and what I found out after the tests came back.  I strongly believe honesty is the best policy.  This is especially true when conveying bad news.

    Patients who have a serious problem know that they do.  A doctor who does not acknowledge this will likely have a patient that feels let down, deceived, lied to, and abandoned.

    My usual office setup is to sit at my desk with the patient in a chair next to the desk facing me, as shown below.  From this position I can comfortably talk with my patients, conduct much of a physical exam, and make phone calls.  More importantly, I can also easily hold a hand, touch an arm or face, and offer a tissue.




    My initial discussion about bad news is straightforward but not blunt.  For example, if cancer is likely, I usually use words such as "tumor" (for solid cancers) or "blood problem" (for hematological malignancies) and schedule a follow up appointment in the near future to go over clarifying information or additional test results.  I tell them I will contact them if something needs to be done before the scheduled follow up appointment.  Similarly, for patients with likely Alzheimer's disease (as much a death sentence for some as cancer), I might describe "cognitive impairment" or "dementia" and defer specifics until the next appointment when more information is available.

    I always follow bad news with suggestions on what to do next.  I offer the pros and cons of each to the best of my knowledge or arrange a specialty consultation (often calling the specialist's office from my desk while they're there).  In addition, I emphasize that I am there for them regardless of what choice of treatment they make, if they have any questions, or need someone to talk to.  I encourage them to page me if they want to talk to me right away.

    Breaking bad news is not easy, but to me it is clearly both my duty and responsibility.  I usually don't cry, but I hope my patients sense that I'm not just an impersonal bearer of information but an empathetic professional and sympathetic friend.  I may even make a joke, not to convey that everything's alright, that I am laughing at their situation, or that the situation is not serious, but to relieve the tension of the situation (both for their sake and mine).

    Conveying bad news becomes a natural part of offering my patients clear, honest information.  I have not regretted being straightforward, and I have not found a patient that reacted in a way that I wish I had not told them.  In fact, I am amazed at the strength people have when spoken to honestly.  As I already mentioned, patients generally know something is terribly  wrong and are usually relieved when they know what it is.

    When my patient finally leaves the office, I usually offer a firm but sensitive handshake, a hug, or an arm around the shoulder.  We'll get together again soon, at which time we'll continue to tackle the issues at hand together.

Copyright 2003 Robert S. Stall MD / Stall Geriatrics

Copies or reprint permission may be requested in writing from:
Robert S. Stall MD
Stall Geriatrics
14 Heritage Road West
Williamsville, NY 14221