CHAPTER 4
Perfect Phrases for Breaking Bad News to Patients and Their Families

Breaking bad news to patients or their loved ones can be a source of extreme stress for healthcare professionals. We are not always prepared for these difficult interactions in medical or nursing school. We might be concerned that our patients will not take the news well and that it could destroy all the hope they have. We can imagine that the patients or their loved ones will be angry with us. Finally, we may feel that we have failed in our job by not securing good outcomes for our patients.

How well these difficult conversations go depends on many factors. A pre-existing relationship between the healthcare provider and the patient can be comforting for all parties involved. Studies have shown that family members named the attitude of the doctor delivering the bad news, the doctor’s ability to answer questions, and a private setting for the conversation as very important.

Unfortunately, it can be very hard to meet all of these goals for communication. Not all healthcare professionals know their patients very well. Some patients may be new to your practice, or they may have been just admitted to the hospital and you are meeting them for the first time. The fast pace of modern medicine does not always allow the time or place to sit down quietly and have long conversations. In addition, it is nearly impossible to anticipate how patients or their families will react to bad news.

In these instances, we have to do our best to deliver bad news professionally and with as much compassion as we can. Having a structure or “game plan” in place ahead of time can be beneficial.

Prepare to Give the News

Try to arrange for a private and quiet place to have the discussion.

Maintain a professional appearance—straighten your tie or white coat, check your hair in a mirror, and take off bloody clothing.

Put your beeper or cell phone on vibrate.

Ensure that you have a complete understanding of the prognosis or diagnosis you are about to present.

Bring a social worker, chaplain, or nurse if you think it will help facilitate communication.

In an academic setting, the attending physician should be present to either supervise the resident or to allow the resident to observe how to deliver the bad news.

Open the Discussion

Clearly identify yourself, your role in the patient’s care, and why you are there.

Introduce yourself to everyone present and find out how they are related to the patient.

Sit down at eye level.

Break the News

Lead off with a very brief summary of the patient’s clinical history.

Give the patient or loved ones a warning statement—”I’m sorry but I have some bad news.”

Break the news using plain language—“The cancer has spread and has become much more serious” or “The car crash was very severe, and he died from his injuries.”

Pause to give the patient or loved ones time to absorb the information, grieve, or simply cry.

Offer to answer any questions.

Close the Interaction

Briefly let the patient or loved ones know what comes next—if the patient has cancer, it may mean seeing an oncologist; if the patient has died, it may mean the body will go to the medical examiner or the family will need to arrange for a funeral home to come collect the body.

If the patient has died, offer the family the chance to view the body, but let them know ahead of time if the patient has medical devices (intravenous tubes [IVs], endotracheal tubes) or traumatic injuries on the body.

Offer the patient and loved ones your continued support or Pastoral Care services.

Close with a final word of empathy.

This “game plan” won’t work for every situation and every patient, so keep the following Pearls and Pitfalls in mind if you have to improvise.

Pearls

Look professional, and behave with the utmost professionalism. Families will remember this moment for the rest of their lives, and your appearance and demeanor will be part of that memory.

Gauge how much information the patient wants to know. Studies have shown that the vast majority of patients want full disclosure about their diseases, but some may not want to know specifics.

Some patients or loved ones appreciate physical touch. If you think it will be helpful, feel free to ask the patient, “Would like a hug or someone’s hand to hold?”

Don’t rush through the conversation. Allow people time to sit quietly, cry, or just process what you have told them.

In the case of death, you may need to discuss an autopsy or organ donation. Use your best judgment to determine if the next of kin are ready for this conversation.

Highlight the positive things patients or loved ones have accomplished, such as “You’ve managed your disease so well since you were diagnosed” or “It sounds like you did just the right thing after your father collapsed.”

Pitfalls

Don’t use medical terminology. Use plain, clear language, and speak slowly.

Arrange for an interpreter if you do not speak the same language as that of the patient and family.

If you don’t know the answer to a question about what happened, don’t guess; instead, let the family know that you will try to find out.

Patients or loved ones may faint at hearing bad news. Make sure that everyone is sitting so that they don’t fall and injure themselves.

You may become the target for anger or blame over the bad outcome. Anticipate tough questions you may be asked.

If a large number of people are present, find the one or two most closely related to the patient, and speak to them privately. Those people can then act as liaisons to the other people.

If the interaction becomes overly heated or you anticipate violence, leave the room immediately.

Always take someone else with you to the encounter, and always make sure you have a clear exit from the room.

Perfect Phrases for Breaking News of an Unfavorable Diagnosis

Mrs. Adams is a 52-year-old woman who visited her family physician’s office two weeks ago to be evaluated for abdominal pain and weight loss. Her physician sent her for a computed tomography (CT) scan which showed extensive peritoneal carcinomatosis. She is back at the office to discuss the results of her scan.

When you are delivering a serious diagnosis, be honest but empathetic. Sit down at eye level with the patient.

→ Thanks for coming back in to discuss your test results. The CT scan results were sent over from the radiology center. I’m sorry to have to tell you this, but they are not good. It appears that you have a very serious cancer, and it has spread all over the inside of your abdomen. This must be just terrible news for you.

Sit quietly, and give the patient all the time you think she needs to absorb this devastating information. The patient or loved ones may have many questions, and you may not be able to answer all of them.

→ Where did this cancer start? Is this going to kill me? How long do I have to live?

Answer the questions to the best of your ability, but don’t make up answers.

→ Those are all good questions, but I can’t answer all of them. I want to arrange for you to see a cancer specialist as soon as possible.

Try to end the interaction on a positive note.

→ We both know that this is a very serious situation. At least we have found out why you have been in pain and losing weight. Now we can move forward and have you see the cancer doctor as soon as possible so we can try to deal with this. As your family doctor, I’ll do my best to be there for you on the road ahead.

Mr. Smith is a 64-year-old man with a long smoking history who was diagnosed with lung cancer six months ago. Since then, he has been undergoing radiation therapy in an effort to shrink the tumors in his lungs. He is visiting his oncologist’s office to discuss his recent positron emission tomography (PET) scan. Unfortunately, the PET scan shows that the lung cancer has widely metastasized.

Assessing what the patient or loved ones knows about the patient’s condition is important. Some patients may be very knowledgeable about medical issues and very involved in their own care. In these cases, the patients may already be anticipating the bad news you are about to tell them because they are aware of the complications of their conditions. Other patients and families may be extremely naïve and have a very limited understanding of their diseases. Some families may even intentionally hide medical information from the patients because they fear how their loved ones will react to the information.

→ I know that you and your wife have been very involved in your care since your diagnosis of cancer. Just so that we are all on the same page, can you tell me what you know about the status of your cancer?

→ Well, I know that it is in my lungs and that the radiation is supposed to be shrinking the tumors.

→ Thank you. That is a good summary of what has happened so far. Do you understand why we did the PET scan last week?

→ I guess it was to see if the cancer is getting smaller?

→ That is one reason. The other is to see if the cancer has spread. Unfortunately, this imaging test shows that your cancer has spread outside of the lung. I want to make sure that you know how much more serious your condition is now that the cancer has spread.

→ Oh no! This is what we were afraid of.

It can be valuable to gauge how much the patient wants to know about his disease.

→ I know you didn’t want to hear news like this. I wish things were different. As your disease has worsened, I feel that I should tell you some of the complications you may encounter. Would you like to discuss them?

→ My wife and I have talked about this. We want to know everything about what is going on even if it’s tough to take.

→ OK. I’m going to respect your wishes, and I’ll keep you informed about all aspects of your medical care.

Mrs. Jones is a 28-year-old woman who came to her gynecologist’s office to be evaluated for pelvic pain and vaginal discharge. After examining the patient the gynecologist is concerned that the patient has a sexually transmitted infection (STI).

Not all bad news that we give to patients is life- or limbthreatening. From a healthcare provider’s point of view, most common STIs are relatively easy to treat and cure. Because STIs have less grave implications than more serious diagnoses such as ovarian cancer or a ruptured ectopic pregnancy, we may underestimate how difficult it may be for a patient to get this news.

Yet from the patient’s point of view, an STI may be a horrifying diagnosis. It may be the first indication that a sexual partner has cheated on her, or the patient may be concerned that she will no longer be able to have children. In such instances, validate the patient’s concerns and educate her about her disease.

→ I’m concerned that you may have an infection of your genital area that is sexually transmitted. I won’t be 100% sure until the results of the samples I took from your vaginal area return from the lab, but I think it would be best to treat you for the STI even before the tests come back.

→ Does this mean my boyfriend has been cheating on me?

→ I can’t say for sure. Your symptoms could be from a non-sexually transmitted infection, or it could be from dormant infection you got from a prior sexual partner. I can give your more answers once the tests come back. In the meantime, I would advise you to have all your sexual partners tested for STIs.

This same scenario can apply to other diagnoses that we make. For instance, a patient who fell and broke his wrist will probably recover fully from his injury in four to six weeks. Yet, if he is the sole breadwinner for his family, missing work for four to six weeks could be financially devastating. Try to keep the effect a diagnosis will have on a patient in mind when you disclose it to him.

Perfect Phrases for Breaking News of Death

According to the Centers for Disease Control and Prevention (CDC), more than 57% of Americans died in hospitals in 2007. Some of these deaths were due to chronic diseases and were expected, whereas others were sudden and unexpected. How the next of kin reacts to news of death can vary, depending on whether the news was expected or not.

Another factor affecting how the next of kin reacts is the healthcare provider’s relationship with them. You may have a close relationship with a patient you have treated for many years. In contrast, in a hospital setting, you can be called upon to pronounce the death of an inpatient that you don’t know anything about and have never met.

Mrs. Smith is a 79-year-old woman with a history of heart failure, who was brought in coding by the paramedics to your Emergency Department (ED). She was treated appropriately, but, unfortunately, she died. Her son has just arrived at the ED and is asking about her condition.

You have called Pastoral Care and asked for the son to be put into a quiet and private room. You have put on your physician’s lab coat, checked your appearance in the mirror, and are on your way to speak to the son.

→ My name is Dr. Mason. I understand that you are Mrs. Smith’s son?

Let the next of kin know your role in the patient’s care.

→ I am the doctor who has been in charge of your mother’s care since she arrived.

Leading off with a very short summary of what has happened until the actual death of the patient can help ease families into the bad news.

→ Your mother was brought here to the Emergency Department from her house about one hour ago. She was found lying in the kitchen. The paramedics did a great job of getting her here quickly and had already put a breathing tube in her throat because she was having trouble breathing. When she got here, her heart was not beating well. We gave her our very strongest medications and ended up having to do chest compressions to keep her blood circulating.

Giving the family a brief warning that you are about to give them bad news can give them a moment to brace for the news.

→ I’m very sorry to have to tell you this …

The words “dead” or “died” might be considered harsh, but they are concrete words that are understood by all. Euphemisms such as “passed on” or “kicked the bucket” or “moved on to a better place” might be misinterpreted or considered insensitive by the patient’s loved ones.

→ … but your mother has died. We tried everything we could, but her heart never started beating on its own.

Pause, and give the loved one time to absorb this news. Allow them to cry or sit silently for as long as you think they need to. When you do speak again, don’t use phrases such as “it was his time” or “she is in a better place” that might seem disingenuous or judgmental. Instead, acknowledge that this is a sad situation.

→ This must be very hard for you, and I can’t imagine what you are going through.

Some people may be incredulous or simply cannot process the news and may be in denial. Express sympathy, but be upfront about the diagnosis or prognosis.

→ She can’t be dead. I just talked to her yesterday! She must just be sleeping. Can’t we just wake her up?

→ I’m very sorry. We did everything we could, but she did not come back.

The pain and suffering that a patient went through before death can be incredibly disturbing to that patient’s loved ones. Loved ones may also feel guilty or responsible for the patient’s death. If you don’t believe that a patient suffered or that his or her death was no one’s fault, some words of empathy can be invaluable. Don’t say things about which you are unsure.

→ She was unconscious the whole time, so I do not believe that she suffered. There was no way that you could have known that this was going to happen.

Offer crying people tissues and the services of the Pastoral Care office. In addition, people will often want to see the body of their loved one to say goodbye.

→ Would you like to see her? Would you like us to arrange for a chaplain to visit with you?

The sight of invasive medical devices in the patient’s body can disturb loved ones. Depending on the circumstances of death and the policies of your local medical examiner’s office, the devices may need to stay in place if an autopsy is to be performed. Warn the patient’s loved ones ahead of time that they should expect to see the devices.

→ Before we take you to your mom, I have to let you know that she had a tube placed in her throat to help her breathe and she still has some tubes in her arms that we were delivering medicines through. These devices are still on her.

At some point, you are going to have to end the conversation and return to your other patients.

→ Is there anything else I can do for you right now? I’m sorry to leave you, but I have to look in on some of my other patients. If you need anything else or have questions, please ask for me, and I will come back and speak to you some more.

Mr. Grover is an older man with many medical problems. He was recently admitted to the hospital for a serious case of pneumonia. His condition worsened during the night, and, unfortunately, he died. You are calling his son, who is his next of kin.

It is best to deliver bad news in person, but at times it may have to be done over the telephone. For instance, the next of kin may live far away from the hospital, or they may insist that you tell them the news over the phone.

→ Are you able to come to the hospital? Your father’s condition has worsened, and we need you to come in.

→ I live really far away from the hospital, and I have to work in the morning. Don’t beat around the bush. Just tell me what’s going on.

Ask a few simple questions to gauge how informed the family is about the patient’s condition.

→ Can you tell me what you know about your father’s condition?

→ The nursing home called me and said he was being taken to the hospital because he had a bad fever and cough. I know that he isn’t too healthy overall to begin with.

→ Yes, he was very ill when he got here to the hospital, and he was diagnosed with a bad case of pneumonia. Last night, he started to get worse. His oxygen levels began to drop, his breathing became labored, and his blood pressure fell. We gave him oxygen and eventually had to give him our very strongest medicines to help keep his blood pressure up. I am very sorry to have to tell you this, but his infection was too serious, and he has died.

→ What? He’s dead? Did you shock him? Dad had a bad heart. I’ve seen on TV people with bad hearts being shocked, and it always works. Did you get him a cardiologist? How come you let him die?

Loved ones can react to bad news with anger and accusations. Don’t take what they say personally or respond with anger. As a professional, you must always take the high road.

→ I promise you that we did all we could to try to save your father. I think his infection was too far along and it overwhelmed him.

→ So it wasn’t his heart?

Answer loved ones’ questions to the best of your ability, but don’t conjecture or make up answers. If you don’t know, you can say that you suspect something or that it is your opinion, but also tell them that you will do your best to find out and can get back to them.

→ I can’t be 100 percent sure that he died from the infection, but it’s my strongest medical opinion. We can’t answer all the questions for sure without an autopsy.

Perfect Phrases for Breaking Bad News About Pediatric Patients

Unfavorable outcomes in the case of pediatric patients can be particularly stressful for all involved. The grief associated with a serious diagnosis or death of a child can devastate healthcare professionals and parents alike. When breaking news of a serious diagnosis, it is fitting to involve the child if he or she is at an appropriate age and level of maturity. Most children begin to understand the concept of death between ages six and nine years. As with patients of all ages, sit down at eye level, use simple words, and stop occasionally to make sure that everyone understands what you are conveying.

In situations where a child is critically ill and may die, it is important that a liaison be established between the family of the patient and the medical team. This liaison could be a nurse, medical student, or social worker, who can explain what is going on with the child and give the family regular updates. There is a growing trend toward bringing family members into the room when a child is being resuscitated. Studies have shown families appreciate being with their loved ones as they die, and it also gives the family the chance to see how hard everyone is working to save their loved one. If this type of family involvement is part of your practice, make sure that the liaison accompanies the family into the resuscitation area.

Justin is a 4-year-old boy who was found floating pulseless in his family’s pool after being left unattended. He was admitted to the pediatric intensive care unit (PICU) after being coded in the ED with return of spontaneous circulation. His clinical condition has further deteriorated and he is pulseless again. A social worker has gone out to the PICU waiting area to let his family know that Justin is being coded again.

Hopefully, by the time this child has been admitted to the PICU, his family knows how serious their child’s condition is. If the family is to be present for the resuscitation, ensure that they have someone with them who can explain what is going on in layman’s terms.

→ Justin’s condition has taken a turn for the worse. The team is working on him right now. I can take you to his room if you would like to be there with him.

If the family is to be in the room, make sure that all of the staff knows that the family is there.

→ Speaking to the staff in the room with the patient: Everyone please be aware that Justin’s parents are going to be coming back and will be in the room as we work on Justin.

→ Speaking to Justin’s parents: I’m sorry to have to tell you this, but Justin’s condition has worsened, and his heart has stopped beating on its own. We are doing everything we can to get it started again. I’m going to ask you to stand over here to the side so that the team can work on him. Nurse Harriman will stand with you and explain what is going on.

The family liaison should not use complex medical terms when speaking to the family. Don’t say:

→ Justin coded, so we commenced ACLS (advanced cardiac life support) protocols and pushed pressors through a central line.

A family is more likely to understand and appreciate what is going on if the following is said:

→ That nurse is doing chest compressions to help the blood circulate to Justin’s brain, and the doctor at the head of the bed is putting in a breathing tube so we can give Justin oxygen directly to his lungs.

If the child dies, the same principles used for breaking bad news about adult patients apply to cases involving pediatric patients as well. However, in the case of the death of a child, the reality of a life cut short does amplify the grief for everyone involved.