‘I’m afraid the news isn’t what we’d hoped’

Having to advise a patient of a poor prognosis is an unavoidable part of most health practitioners’ jobs, and it is never easy. Recognising the importance of doing this well, and being prepared, can help ensure such consultations go as well as possible, for you and for the patient.

Mr S suffers from diabetic retinopathy and has come to you for his regular eye examination. He has been able to continue driving, but you now believe his vision has deteriorated to the point where he is no longer safe to drive. How do you tell him?

Being prepared to deliver bad news 

Such a consultation is often challenging, and it is essential you communicate very clearly so Mr S understands what you are telling him, and the implications. Preparing as much as possible for the consultation is important.

Some of this preparation will involve practical issues:

• Bad news can take time for patients to process, can you take extra time if needed for a difficult consultation?
• Do you know what the next steps for the patient’s care will be?
• Do you have information in a form they can take away with them – including referrals to support services if necessary?
• It is always important that the discussion occurs in an appropriate setting to protect the patient’s privacy, but consider whether the patient will need support or interpreter services for the consultation.

Some practitioners also find it helpful to have considered and rehearsed common scenarios in their field.

Having the discussion 

Even if you can only spend a few moments, collect your thoughts and think about how to approach the discussion. If you have a long-standing relationship with the patient, you may already have talked about how their condition may progress. Nevertheless, the news will likely still come as a shock and it is important to recognise and allow for a patient’s emotional response.

In either case, it is also often helpful to start by checking what the patient knows about their condition, or what others have told them. This can help you understand what they are expecting to hear, and to focus on information they need.

In a situation like this, it is understandable if you feel sorry for the patient, having to tell him he can no longer drive. He may be upset or angry. Some patients may try to exert pressure on you to change your assessment. Approaching the conversation with care and demonstrating respect and concern for the patient will help. It is important though to remain objective and clear in your assessment, and ensure you are not swayed by patient pressure. Never offer false or misleading hope.

Patients may have many questions about the prognosis and implications, so be as prepared as possible before the consultation. However, always take your lead from the patient; check how much information they want and can take in. Speak clearly and try to avoid using medical jargon. Consciously try to pause and break the information into small chunks. This will allow a patient more time to absorb it, and moments of silence will give them an opportunity to ask questions or express concerns.

If patients do have questions, always try to answer as concisely as possible. Avoid speculation and if you don’t know the answer, be confident to say so.

At some point it may be important to ask whether the patient will need support to tell relatives or carers. However, make sure you prioritise the patient’s privacy and only speak to family with the patient’s permission. You may also need to discuss a plan for informing other health practitioners involved in the patient’s care.

Before you finish, summarise the discussion and ensure the patient has had enough opportunity to ask questions.

Reinforce what you agreed about next steps, follow-up appointments or referrals. Provide any appropriate further information, including about support services. Make sure the patient knows how to get in contact if they have further questions. Check they can get home safely.

Document the discussion 

Patients who receive a shock are particularly likely to mishear, or misremember, what was discussed in a consultation. Always document the details of the consultation carefully, including the names of anyone else present, the matters discussed with the patient and information provided.

It is good practice to keep a copy of the actual version of any prepared information you provide as such publications are regularly updated and may have changed if you ever need to check what the patient was told at the time.

Finally, remember to take care of yourself. Delivering bad news can challenge even the most experienced practitioner, so make sure you have your own support strategies.

ABOUT THE AUTHORS:

Dr Mark Woodrow is a Senior Medical Adviser and Claims Manager at Avant, a full-time emergency physician and facilitates workshops on risk management and communication in healthcare.