Special Feature
Breaking Bad News: Balancing Honest Disclosure With Hope
By David M. Gershenson, MD
At one time or another, all obstetrician-gynecologists are in a position of communicating bad news to patients and/or their families. Such an experience may involve an obstetrical mishap, a perinatal or maternal death, a postoperative complication or mortality, care of an infertility patient, or care of a cancer patient. Most of us never received any formal training in this area. For the majority of physicians, the learning process has been derived through experience. Of course, my perspective is that of an oncologist, but the overriding principles apply in several different situations and, at one time or another, affect all practicing obstetrician-gynecologists.
Kodish and colleagues note that, in the early 1960s, the vast majority of physicians did not tell patients about a diagnosis of cancer.1 By the late 1970s, almost all physicians believed in telling patients of a cancer diagnosis. Patient attitudes have changed dramatically as well. The medical profession is no longer held in such high esteem by many of our patients. As we near the end of this millennium, the emphasis has shifted from diagnosis to prognosis. How much do we say about the probability of remission or cure? How specific can or should we be? There are no precise guidelines, and, most importantly, the amount and nature of the disclosure should be individualized based on how much the patient wants to know at the time. As Kodish et al point out, "Doctors must be honest with their patients, but must also use common sense and understand human nature."
Breaking bad news comes easily to very few of us, even today. In general, I find that my younger colleagues are better at this process than I or my older associates. In preparing to discuss a cancer diagnosis and poor prognosis with a patient and her family, it is important to assume an attitude of caring, compassion, and sensitivity. So many of the complaints I hear about other physicians surround the stiff and insensitive manner in which they communicated bad news.
Over the past few years, several authors have addressed the issue of breaking bad news. In a nice review article, Girgis and colleagues outlined a series of 16 principles for breaking bad news.2 Based on these principles, Girgis et al recommend several important steps: 1) ensure privacy and adequate time; 2) assess the patient’s understanding; 3) provide information simply and honestly; 4) encourage patients to express feelings; 5) give a broad time frame; 6) arrange review of the situation in the immediate future; 7) discuss treatment options; 8) offer assistance to tell others; 9) provide information about support services; and 10) document information given.
Robert Buckman, a Toronto physician, has also written extensively about this subject, and has authored a wonderful book entitled, "How to Break Bad News—A Guide for Health Care Professionals." Buckman recommends a six-step process that encompasses many of the same principles as those summarized by Girgis et al.3 His recommendations include: 1) selecting the appropriate setting and the parties to be involved (e.g., the interview should be conducted in person, not over the telephone); 2) finding out how much the patient knows; 3) finding out how much the patient wants to know; 4) sharing the information (aligning and educating); 5) responding to the patient’s feelings; and 6) planning and follow-through.
Over time, each physician develops his/her own style and protocol for breaking bad news. Again, the major challenge is to balance honest disclosure with the promotion of reasonable hope for the patient. Even though I have been breaking bad news for several years, I still believe that this is a dynamic process in which one can constantly improve his/her skills. We have much to learn from our patients and about the human spirit.
References
1. Kodish E, et al. J Clin Oncol 1995;13:1817-1822.
2. Girgis A, et al. J Clin Oncol 1995;13:2449-2456.
3. Buckman R. How to Break Bad News-A Guide for Health Care Professionals. Baltimore, MD: The Johns Hopkins University Press; 1992.
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