Conveying bad news is never an easy task, but physicians can take heart in knowing that it’s a learnable skill.
Before Joe Rotella, MD, MBA, would begin to discuss end-of-life care, he found a quiet space where he and a nurse or a social worker could sit with a patient and loved ones in a circle.
“The first thing we end up doing is moving all the furniture around,” says Rotella, chief medical officer at the American Academy of Hospice & Palliative Medicine. “It doesn’t help to have difficult conversations standing up with your hand on the door knob. You really need to be present.”
Conveying bad news is never an easy task, but physicians can take heart in knowing that it’s a learnable skill. The best way is to practice, with mentors and coaches who offer constructive feedback.
Training in palliative care has lagged behind demand, as an aging population continues to surge. In some locations, particularly rural areas where palliative specialists aren’t available, family physicians often take on this role, according to a study published in the March-April 2017 issue of the Journal of the American Board of Family Medicine.
These conversations are challenging for a variety of reasons. Clinicians may become overrun with emotions and may be unsure of how to answer questions posed by patients, says Claire Ankuda, MD, MPH, a co-author of the study and a palliative care researcher in the Robert Wood Johnson Foundation Clinical Scholars Program at the University of Michigan.
“Everyone is different in terms of what they want,” she notes. “Some patients really want to hear all the details. Some only want to hear the broad strokes” during the initial conversation.
It’s important to let patients take the lead and for physicians to share the news in simple terms. Then it’s time to be silent and allow patients to process the information and react. Talk about subsequent steps only if patients express interest and ask them to repeat what they heard, Ankuda says.
“Physicians live in this world of medical language,” she adds. “Patients may not have the same understanding.”
Giving patients the opportunity to make their values and wishes known is essential. Advance care planning has increasingly become a key element in managing patients with critical illnesses, says Shauna Conry, MD, director of the palliative care program at CEP America, a nationwide partnership of more than 2,000 emergency room physicians as well as hospitalists, anesthesiologists and critical care specialists, with headquarters in Emeryville, Calif.
In 2013, Conry helped launch a national education program that equips providers with the tools to have difficult discussions about goals of care in the emergency department and beyond.
“Sometimes a new diagnosis is made in the ER or a trauma has changed the course of someone’s life,” says Conry, an emergency room physician. While seeing patients in their worst state, “it’s a poignant time to make an impact on the course of their health care trajectory.”
Surveys indicate that a majority of patients would prefer to die in a peaceful manner without extensive life-prolonging measures.
“Most people, when they understand what they’re up against, don’t want to end up dying on a machine where they can’t talk to their loved ones,” says Anthony Back, MD, co-director of the Cambia Palliative Care Center of Excellence at the University of Washington, where he is a professor of medicine in the division of oncology.
His research focuses on how improved patient-clinician communication can make a difference. “There’s a big disconnect between what patients say they want and what actually happens,” he says.
Susan Kreimer is a freelance health care writer based in New York.