When Bad News Is Delivered Which Is Action Is Most Likely to Reassure Patient and Family

J Gen Intern Med. 2002 Dec; 17(12): 914–922.

The Expert News About Giving Bad News to Patients

Neil J Farber, Doctor,^ane Susan Y Urban, MD,² Virginia U Collier, Medico,ⁱ Joan Weiner, PhD,ⁱⁱⁱ Ronald M Polite, MD,^one Elizabeth B Davis, PhD,⁴ and E Gil Boyer, EdD^iv

Neil J Farber

¹Received from Christiana Care Health System, Wilmington, Del

Susan Y Urban

ⁱⁱNew York Academy School of Medicine, New York, NY

Virginia U Collier

¹Received from Christiana Care Health System, Wilmington, Del

Joan Weiner

^threeDrexel University, Philadelphia, Pa

Ronald G Polite

¹Received from Christiana Care Health System, Wilmington, Del

Elizabeth B Davis

⁴St. Joseph'southward University, Philadelphia, Pa

E Gil Boyer

⁴St. Joseph's University, Philadelphia, Pa

Abstract

Background

There are few information bachelor on how physicians inform patients about bad news. Nosotros surveyed internists almost how they convey this data.

METHODS

We surveyed internists almost their activities in giving bad news to patients. One set of questions was about activities for the emotional support of the patient (11 items), and the other was about activities for creating a supportive environment for delivering bad news (9 items). The impact of demographic factors on the performance of emotionally supportive items, environmentally supportive items, and on the number of minutes reportedly spent delivering news was analyzed by analysis of variance and multiple regression assay.

RESULTS

More than half of the internists reported that they always or ofttimes performed ten of the 11 emotionally supportive items and half-dozen of the 9 environmentally supportive items while giving bad news to patients. The average fourth dimension reportedly spent in giving bad news was 27 minutes. Although training in giving bad news had a significant touch on the number of emotionally supportive items reported (P < .05), only 25% of respondents had whatever previous training in this area. Being older, a woman, unmarried, and having a history of major illness were also associated with reporting a greater number of emotionally supportive activities.

CONCLUSIONS

Internists report that they inform patients of bad news accordingly. Some deficiencies exist, specifically in discussing prognosis and referral of patients to back up groups. Doctor educational efforts should include discussion of prognosis with patients every bit well as the availability of support groups.

Keywords: communication, bad news, stop-of-life care

Studies have shown that physician advice skills can affect patient satisfaction,^{i , 2} compliance with treatment,^ane quality of life,³ and health outcomes.^{4 , 5} Poor communication skills have been linked with physician burnout,^{6 , 7} professional dissatisfaction, and increased litigation.^{8 , ix} Giving a patient bad news, for example, that he or she has cancer, poses a special challenge in patient–doc communication.

For patients, receiving a diagnosis of cancer or other bad news causes great stress and can lead to psychological morbidity.^{x – 12} Studies take suggested that doctor advice can affect the psychological well-being of patients being given a diagnosis of cancer.^{13 – nineteen} Many patients prefer a patient-centered style of communication.²⁰ Authors stress the importance of giving information that is perceived as adequate and eliciting and responding to the emotional reaction of each patient.^{11 , 13 , 21} Patients may be more than probable to develop psychiatric disorders when they practise not receive the information that they want or practice not receive sufficient attending to their emotional responses.^{11 , 21}

In the last decade, several authors have published recommendations and guidelines for breaking bad news.^{22 – 34} In that location is little evidence about the best methods for giving bad news, so most guidelines are based on opinion.^{27 , 35} The guidelines generally recommend individualized disclosure, i.east., tailoring the interview to the individual patient.²⁸ Nondisclosure is no longer considered ethical. Yet, complete disclosure without regard for the patient's readiness for the information is too inappropriate. Patients differ in their reactions to existence given bad news and in their needs during this emotional time.

Buckman²² developed a 6-step protocol including the post-obit: 1) giving the news in person, in private, with plenty time and without interruptions; 2) finding out what the patient knows almost the diagnosis; 3) finding out what the patient wants to know; 4) sharing the information, which includes giving a warning shot and so a pocket-sized amount of information in simple language at a pace the patient can handle, with a caring and honest attitude; Buckman includes eliciting and listening to the patient's fears and concerns in this fourth pace; five) responding to the patient'due south feelings, which includes identifying, acknowledging, and validating his or her reaction; 6) planning and follow-through, which includes planning the next steps, summarizing what has been said, identifying sources of support, and making an early follow-up engagement.

At that place are relatively few information on how physicians actually give bad news. Ford et al.³⁶ in the U.k. have analyzed oncologists' interactions with their patients. In Ford'southward analysis of audiotaped interactions, she institute trivial psychosocial exchange compared to biomedical substitution, few empathic responses of physicians to their patients, and high medico control over the interviews. Several studies have shown that physicians do not detect or they under-rate distress in their patients. For instance, Fallowfield et al.^thirteen constitute that surgeons did not detect emotional distress in women with breast cancer in 70% of cases. Ford et al.³⁶ found that oncologists nether-rated distress in their cancer patients. Other authors^{37 – 41} also have found that oncologists do not detect or assist patients well with their psychosocial issues.

There are even fewer data on how physicians in the Us give bad news. Eggly et al.⁴² analyzed videotapes of general internal medicine residents giving the diagnosis of lung cancer to simulated patients. They found a mean rating of 3.42 on informative items out of a possible 5 and a mean rating of 3.45 on melancholia items out of a possible v. They plant that the residents had the most difficulty in eliciting the patients' perceptions of the problem before giving bad news, exploring whether the patient wanted to receive the news, and eliciting the patient's emotional reaction to the news.

The purpose of the electric current study was to survey practicing internal medicine physicians in the Us on their self-reported practices in giving bad news. We also nerveless information on demographic factors and prior training in communication skills or personal feel with illness that could affect how these physicians requite bad news.

METHODS

We conducted a cantankerous-sectional mail survey of 1,000 randomly selected practicing internists in the United States, identified through the American Medical Association (AMA) master file, a comprehensive list of U.S. physicians, not limited to AMA members. Students, residents, and non-practicing physicians were excluded. To test the hypothesis that there is a divergence in how specialists and full general internists deliver bad news, the study, which was canonical past the Institutional Review Board of Christiana Care Health Arrangement, included 500 general internists and 500 medical subspecialists.

Each physician received an anonymous questionnaire along with a $v incentive. A second questionnaire was mailed to all nonresponders. All responses received earlier June one, 2000 were included in the analysis.

The survey presented a hypothetical patient with metastatic carcinoma of the liver and lungs with an unknown primary. Items in the survey were developed from a study²⁸ that used a consensus panel consisting of 28 medical oncologists, general practitioners, surgeons, nurses, social workers, clergy, and human rights representatives, forth with 100 patients diagnosed with cancer inside the previous 6 to 12 months. Items recommended by the console and indicated as essential or desirable by more than 70% of the patients were included.

11 questions ascertained information near how internists give bad news and the emotional support that they provide to patients and their families. These questions included providing support to the family when giving bad news, finding out how much the patient wants to know, fugitive the use of specific statistics on survival, touching the patient on the manus or arm while giving bad news, giving an indication that things are serious before giving the details about the bad news ("warning shot"), carrying some kind of hope to the patient, fugitive giving the patient a specific corporeality of fourth dimension that he/she will live, inquiring most the patient's worries, fears and concerns, starting the process of giving the bad news past kickoff assessing the patient'southward understanding of his/her status, encouraging the patient to limited his/her feelings, and avoiding telling the patient that "everything will exist all correct" when conveying bad news.^{22 , 28 , 33} These items are referred to in this paper as emotionally supportive items.

9 questions addressed the concrete and social aspects of giving bad news in the office setting. These questions included ensuring that the bad news is given in a individual setting, picking a time for giving bad news that is user-friendly for the patient and his/her family, sitting in a chair next to the patient (rather than behind a desk) when giving bad news, avoidance of a white lab coat when giving bad news (this item was included on the ground of suggestions during pretesting), referral to a cancer support grouping, ensuring that a back up person is present when giving bad news, asking the receptionist to hold all phone calls when giving bad news, turning off the beeper or having someone concord it when giving bad news, and the avoidance of giving bad news by telephone.^{22 , 23 , 28 , 33} These items are referred to in this paper as environmentally supportive items. Respondents were asked to indicate how frequently they would perform each behavior, based on a 4-point Likert-type calibration (e'er, frequently, rarely, never).

Items were framed and so that a mix of positive and negative responses were deemed optimal (Appendix A). Demographic questions nearly the respondents were also included. The survey was pretested for face and content validity amidst 25 practicing physicians at Christiana Care Health Organisation. Respondents in the pretest completed the questionnaire, and were then questioned about their understanding of each of the items on the survey instrument.

Data were entered for analysis manually past 2 individuals. In a cross-bank check of 30% of the entered data, no errors were detected. The furnishings of the demographic information on the number of activities indicated equally beingness performed by respondent physicians always or frequently for each of 2 broad aspects of giving bad news (emotionally supportive items and environmentally supportive items) were analyzed by analysis of variance. Demographic variables included age, gender, marital status, life-threatening illness in the respondent, life-threatening disease in a spouse, yr of medical school graduation, prior training in giving bad news, location and type of practice, percent of time seeing patients, specialty/subspecialty, and percent of practice in chief care. Demographic variables demonstrating a meaning association (P < .05) with the outcome in a univariable regression model were entered into multivariable models. The dependent variables in these models were the number of emotionally supportive items that the respondents reported every bit doing always or often and the number of environmentally supportive items that the respondents reported as doing always or oftentimes.

RESULTS

Of the 1,000 questionnaires, 26 were returned undelivered, and 13 physicians had retired from practice. Of the 961 internists who were eligible and received surveys, 461 (48%) returned questionnaires. Respondents' demographic and professional person characteristics are shown in Table i. The responding physicians had an average historic period of 50 years and were largely male, white, and married. While a majority of respondents (63%) had experienced a life-threatening illness in a spouse or loved i, but 17% had personally experienced such an disease. The practices of almost respondents were in urban or suburban settings, and most were in individual practices; full general internists and subspecialists were as represented. Physicians spent an average of 84% of their time seeing patients, with 65% of the time spent in master care. Every bit expected, there was a pregnant deviation betwixt generalists and subspecialists, with generalists spending 94%± sixteen% of their time in primary intendance, while subspecialists spent 35%± 37% of their fourth dimension in primary care (P < .001). Responses past physicians in different subspecialties and general internists were non significantly dissimilar (although numbers in each subspecialty were small), and therefore the results are pooled for the entire respondent group. Only 25% of the respondents had received any type of training in how to give bad news to patients.

Tabular array 1

Characteristics of Responding Physicians^*

Feature	Value
Hateful age, y ±SD	50 ± 11
Gender, n (%)
Male	365 (79)
Female	94 (20)
Marital condition, n (%)
Married	401 (87)
Divorced	21 (5)
Single	31 (vii)
Widowed	five (1)
Having a spouse or loved one with a life-threatening illness, due north (%)
Aye	292 (63)
No	166 (36)
Yourself having had a life-threatening illness, n (%)
Yep	77 (17)
No	382 (83)
Specialty, n (%)
General internal medicine	233 (51)
Medicine subspecialty	227 (49)
Exercise type, n (%)†
Individual practice	326 (71)
Bookish medicine	75 (xvi)
HMO	52 (xi)
VA	20 (four)
Other	vii (two)
Do locale, north (%)
Urban	214 (46)
Suburban	182 (39)
Rural	60 (13)
Percentage of time seeing patients, mean ±SD	85 ± 20
Per centum of practice devoted to primary care, hateful ±SD	65 ± 41
Training in giving bad news to patients, north (%)
Yes	113 (25)
No	347 (75)

Near of the physicians who responded to the survey indicated that they always or frequently provided 10 of the xi emotionally supportive items to the patient and the family at the time that bad news was communicated (Fig. 1). However simply 16% of physicians always or oft avoided giving specific statistics of survival to patients.

Percent of 461 respondent physicians performing emotionally related items always or often.

Fewer physicians attended to the environmentally supportive items involved in giving bad news to patients (Fig. 2). A minority of respondents always or frequently avoided wearing white lab coats (34%), turned off their beepers (35%), and referred the patients to support groups when giving bad news (38%). The average amount of fourth dimension spent giving bad news was 27 ± 12 minutes.

Percent of 461 respondent physicians performing structurally related items e'er or frequently.

Several demographic features of the respondents were associated with the number of emotionally supportive items performed always or ofttimes as determined by multiple linear regression analysis (Table 2). Age >50 (P = .013) and a personal feel with a life threatening illness (P = .007) were both associated with an increased number of emotionally supportive items existence done always or frequently. Existence married (P = .015) was negatively associated with these factors being performed. Female person physicians who responded were significantly more probable than were male physicians to provide emotionally supportive items to patients and their families (P = .002) and to spend more fourth dimension with patients when giving bad news (31 ± 14 minutes for female physicians, 26 ± xi minutes for male physicians; P = .001). Training in giving bad news was associated with an increased frequency in providing emotionally supportive items (P = .026). There was no departure seen between generalists and subspecialists.

Table 2

Demographic Factors Independently Associated With Number of Emotionally Supportive Items Performed Ever or Frequently by Respondents

Variable	Items*	P Value
Age
≥50 y	8.i ± 1.6	.013
≤49 y	vii.eight ± ane.7
Married
Yes	vii.9 ± ane.6	.015
No	viii.four ± 1.iv
Personal disease
Yes	8.5 ± ane.4	.007
No	vii.8 ± i.half-dozen
Previous training
Yes	viii.ii ± 1.six	.026
No	7.9 ± one.six
Gender
Female person	viii.4 ± ane.iv	.002
Male person	seven.8 ± one.7

The merely demographic gene associated with the frequency of engaging in recommended environmentally supportive items in giving bad news as determined past multiple linear regression analysis was the blazon of practise of the respondents. Physicians who engaged in private practise were significantly more than likely to provide environmentally supportive items for the do good of the patient than were physicians who did non engage in individual practice (P = .031). No other demographic variables were associated with these factors, and previous preparation in how to give bad news to patients had no effect.

Discussion

A number of authors^{28 , 32 , 33} have suggested ways in which physicians can more empathically inform patients and their families nearly bad news. In this written report, respondents stated that they always or often used most of these emotionally supportive items when informing patients of a life-threatening affliction such as metastatic cancer. However, when discussing prognosis, many physicians in this study indicated that they ordinarily give specific statistics well-nigh likelihood of survival to patients, and a big percentage of respondents stated that they informed patients of a specific predicted length of life.

Near guidelines have suggested that patients exist given a range of time of survival and averages in terms of prognosis, rather than specific times of survival and statistics.²⁸ Information technology is impossible to know the exact time of survival of any given patient. Statistics refer to populations, whereas the individual patient may fall above or beneath the hateful in terms of their survival. Before giving data virtually prognosis, it is also important to know the question that is being asked past the patient. In 1 study⁴³ of 32 patients recently diagnosed with cancer, just 1 participant requested a specific life expectancy, and initially regretted having asked for the information. When information is given most prognosis, it is of import to tailor that data to the needs and desires of the patient (individualized disclosure). Thus, although many of the emotionally supportive items of giving bad news are attended to by internists in this study, there is a need for changes in how prognosis is conveyed to patients.

Although a majority of respondents in this study did ensure that no telephone calls would interrupt the coming together with a patient when giving bad news, simply a small percentage indicated that they routinely turned off or handed off their beepers. Thus, interruptions may exist occurring when these physicians give bad news to patients. A consensus console of clinicians and patients recently diagnosed with cancer indicated that avoiding interruptions when informing patients nigh bad news was important,²⁸ and some authors suggest turning off beepers or giving them to a colleague to hold.²³ There is no consensus on wearing white coats while giving bad news, so it is not surprising that a majority of participants in this study did not avoid wearing them.

Peradventure most surprisingly, a bulk of the responding physicians did not routinely refer patients to back up groups when informing them of bad news such as a life-threatening illness. Referral to back up groups has been advocated by some authors.²⁸ Studies^{12 , 18} suggest that patients who feel supportive dr. interaction cope in a more effective manner with concluding illnesses. Back up from peers with a like disease state could also increase patient aligning and subtract feet. In one study⁴⁴ on parents who were informed of their newborn kid's cleft lip and/or palate, it was demonstrated that 67% of those surveyed strongly desired to have such support. In another study,⁴⁵ supportive-expressive group therapy was institute to increment the quality of life in metastatic breast cancer patients by improving mood and decreasing the perception of pain. Therefore, at that place is information nigh the benefits and availability of support groups that should be disseminated to physicians.

Several demographic features of the responding grouping of physicians in this report were associated with an increased attendance to the emotionally supportive and/or environmentally supportive items of informing patients about bad news. It is not surprising that respondents who had personally experienced a life-threatening illness were more than attentive to the emotionally supportive needs of their patients. Several authors^{46 – 48} accept written of their own personal experiences with illness and how it changed the way in which they communicated with patients. Similarly, ane might wait that equally physicians historic period they would consider such emotionally supportive items more prominently in their dealings with patients. In fact, the respondents in this study who were over the age of 50 years were more than likely to take reported performing emotionally supportive items of giving bad news than were younger physicians.

Female physicians who responded to this survey spent more time than their male counterparts when informing patients about bad news, and engaged in more than emotionally supportive items than did male person respondents. One might question whether female person physicians are inherently more than nurturing, or if their training and previous experiences accept allowed them to exist more circumspect to patients' emotional needs. Further work in this area is warranted.

Those respondents who indicated that they had received some type of previous training in communicating bad news were more than likely to attend to the emotionally supportive aspects of informing patients most a life-threatening illness than were respondents without such prior grooming. However, just 25% of respondents had received any type of educational activity in this surface area. Studies⁴² accept demonstrated that residents generally lack the necessary competence in delivering bad news to patients. Training can brand a pregnant difference in how bad news is communicated to patients, every bit demonstrated past Baile et al.⁴⁹ in their study of practicing oncologists and past Fallowfield et al.^fifty in a report in the Great britain.

This study has some limitations. The data are self reports by physicians; no attempts were made to assess the actual behaviors by general internists, subspecialist internists, or other types of physicians in giving bad news to patients. Thus, respondents may accept reported that they engaged in such behaviors more than they actually did, and may have not performed some of the behaviors in a competent fashion. These possibilities simply serve to emphasize the demand for more than educational interventions for physicians in this of import area of advice.

Second, the low response rate may introduce the possibility of nonrespondent bias. However, the age, gender, and specialty distribution of the respondents in this survey is similar to that of practicing physicians in the United States in 1997–1998.⁵¹ One would doubtable that the nonrespondents were those physicians who once again were either not engaging in the communication of bad news to patients, or who were not interested in the topic, even though they did deliver bad news to patients. If the latter was the example, it would more strongly point out the need for greater physician awareness of the importance of giving bad news in an appropriate manner.

Third, the hypothetical case used in the survey was that of a patient diagnosed with metastatic carcinoma. The survey did non vary the type of bad news communicated to the hypothetical patient. How physicians communicate bad news may be dependent upon the clinical situation and their familiarity with the medical condition.

Finally, this study did non attempt to assess patients' opinions nearly how bad news is communicated or whether the specific guidelines impact on patient satisfaction or on outcomes. Areas for further written report include objective assessments by patients or md educators on how physicians give bad news; whether the published guidelines on giving bad news reflect patients' expressed needs and desires; and whether conveying bad news according to current guidelines impacts on patient satisfaction and clinical outcomes.

In summary, internal medicine physicians written report that they exercise generally recognize and perform many items as recommended in the literature in giving bad news to patients. However, many internal medicine physicians written report that they practice non convey prognosis as recommended by some authors, and only a minority would refer patients to back up groups. Educational efforts for physicians in giving bad news should include discussing prognosis with patients. Additionally, physicians should be made aware of the availability and possible benefit of support groups for patients. These results tin help guide both undergraduate and postgraduate medical education curriculum development.

Acknowledgments

This work was supported by a grant from the Osler Fund, Department of Medicine of Christiana Care Health Arrangement.

Appendix A

Survey Instrument

End-of-Life Advice Study Grouping
We are interested in the mode in which y'all give bad news to patients. Your completion of this survey is totally voluntary; all the same, should yous decide to participate, we ask that yous complete all questions as fully as is possible. Delight exist assured that your answers will remain totally confidential, and yous will not be identified on this questionnaire. Although not sufficient to reimburse you for your fourth dimension, please have the $5.00 bill every bit a token of our appreciation.
Neil J. Farber, Md  Susan Y. Urban, Doctor  Ronald Polite, MD
For each of the following questions, we enquire y'all to assume that you are telling a patient that he or she has carcinoma of an unknown main that has metastasized to the liver and lungs, so that simply palliative therapy is available.
For a patient such as the one presented above, how often would you do each of the following (check one box for each question):
	E'er	Oft	Sometimes	Rarely	Never
1. Provide support to the family (when they are bachelor) when giving bad news to the patient	□	□	□	□	□
2. Find out how much the patient wants to know before giving bad news	□	□	□	□	□
iii. Requite specific statistics to patients nearly survival of life-threatening illnesses	□	□	□	□	□
4. Affect a patient on the hand or arm when giving bad news	□	□	□	□	□
five. Give an indication that things are serious before giving details most bad news	□	□	□	□	□
six. Ensure there is some kind of hope conveyed to patients when giving bad news	□	□	□	□	□
vii. Give a definite corporeality of time of survival when giving bad news if the patient asks	□	□	□	□	□
8. Ask as to patients' worries, fears, and concerns when giving bad news	□	□	□	□	□
9. Start giving bad news past first assessing the patient's understanding of his/her status	□	□	□	□	□
10. Encourage the patient to limited his/her feelings when giving bad news	□	□	□	□	□
xi. Tell the patient that everything will be all correct when giving bad news	□	□	□	□	□
For the following questions, we ask you lot to assume that you are informing the patient of his/her metastatic carcinoma in your outpatient office. If you do not have such an office, please answer as many of the following questions as utilise to you, and betoken North/A next to whatsoever question that does not employ.
How often do you (check one box for each answer):
	Always	Oft	Sometimes	Rarely	Never
12. Ensure that the meeting with the patient to give bad news is washed in private	□	□	□	□	□
13. Pick a fourth dimension to give bad news that is most convenient for the patient and his/her family unit	□	□	□	□	□
fourteen. Sit in a chair next to the patient rather than behind your desk when giving bad news	□	□	□	□	□
xv. Wear a white lab coat when giving bad news	□	□	□	□	□
16. Refer the patient to a cancer back up group after giving bad news to the patient	□	□	□	□	□
17. Ensure that the patient has a back up person present when giving bad news	□	□	□	□	□
eighteen. Inquire your receptionist to concord all phone calls when giving bad news to a patient	□	□	□	□	□
xix. Turn off your beeper (or enquire someone to hold it) when giving bad news to a patient	□	□	□	□	□
20. Give bad news to a patient by telephone	□	□	□	□	□
21. On average, how much fourth dimension exercise you normally spend with the patient when informing him/her of the bad news?
_________________________minutes
We need some information nearly yourself:
22. Age__________
23. Gender (check one): □Male □Female
24. Marital status (check one answer):
□Married □Divorced □Single □Widowed □Other_____________
25. Has a spouse or other loved 1 ever experienced a life-threatening illness (bank check one answer)?
□Aye □No
26. Accept you ever experienced a life-threatening illness (cheque one answer)?
□Yes □No
27. Year graduated from medical school _________
28. Have you had any training in how to requite bad news to patients, other than informally on rounds (check ane answer)?
□Yes □No
If then, was it in (bank check all that apply):
□Medical school
□Residency
□Fellowship
□Standing medical
□Other__________
29. How would you characterize the locale which you practice (bank check one reply)?
□Urban □Suburban □Rural
xxx. How would you narrate your type of exercise (bank check all that apply)?
□Private exercise
□HMO practice
□Academic faculty
□VA
□Other_____________________
31. What pct of you lot professional time is spent seeing patients? _______________%
32. What is your medical specialty? ____________________________________
33. What is your medical subspecialty? ____________________________________
34. What percent of your practice is devoted to primary care? _________________%
Thanks FOR YOUR Aid.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495144/

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