How to Deliver a Difficult Medical Diagnosis

Contributor: Mona Gupta, MD, Palliative Medicine and Supportive Oncology, Solid Tumor

With any difficult diagnosis, medical professionals may struggle with allowing patients to feel sad. It could be their own personal discomfort in not knowing how to help or because they lack training in how to communicate bad news.

Also, we need to be sensitive to the fact that when patients first get a difficult diagnosis, they are overwhelmed. We need to realize that they may be saying “yes” and nodding their head but the chances that they are integrating the information and getting back to us on their understanding of the cancer process are slim. Basically, patients are in shock.

It’s important to allow patients to express their emotions. If patients don’t express, they don’t deal well with their feelings. By giving them the space to feel whatever they feel, medical professionals do a great service for patients. Physicians need to allow the emotions to happen naturally without letting their own beliefs get in the way. It’s also important that they don’t medicate these patients too quickly because those feelings are the body’s natural way to cope.

Often medical teams are hesitant to give bad news and don’t speak in terms that people understand. But we need to communicate with patients in clear, understandable language. If we can deliver difficult news in the right way, patients take it better and process the news better. This means using appropriate body language and tone of voice with a focus on the patient (not doing three things at the same time). Besides your expertise, presence is the most important gift that you can offer to your patients.

When giving bad news, it’s important to make sure that there is time for discussion and questions. In my practice, we use SPIKES protocol for delivering bad news:

• Setting up the interview (Review the plan for telling the patient and how you will respond to any emotional reactions or difficult questions; manage time constraints and interruptions)
• Perception (Seek to understand how the patient perceives the medical situation – what it is and whether it is serious or not; e.g. you can ask “What do you understand about your medical condition?”)
• Invitation (Ask patients: “How would you like me to give the information about the test results? Would you like me to give you all the information or sketch out the results and spend more time discussing the treatment plan?”)
• Giving Knowledge and information (Warn the patient that bad news is coming may lessen the shock, i.e. “Unfortunately I have some bad news to tell you…” or “I’m sorry to tell you that…”)
• Addressing Emotions with empathetic remarks (Observe any emotions of the patient, whether tears, a sad look, silence or shock and work to identify the emotion to yourself. If the patient is sad but silent, use open-ended questions to help you understand their thoughts and feelings.)
• Summary (Before discussing a treatment plan, ask patients if they are ready at that time for such a discussion. Checking for any misunderstanding on the patient’s part can also prevent the tendency for patients to overestimate the effectiveness of treatments or their purpose.)

We need to recognize that cancer process is a series of challenges and obstacles that patients need to surmount in order to move on to grab the next challenge.