feature
Being the Bearer of Bad News
Guidelines for preparing and delivering bad news to patients.
BY LESLIE GOLDBERG, ASSOCIATE EDITOR

How do you deliver bad news to a patient? This responsibility represents a significant challenge for the majority of eyecare professionals, and medical professionals in general. Gregg K. VandeKieft, M.D., said in his article "Breaking Bad News" that appeared in American Family Physician, "Breaking bad news to patients is one of the most difficult responsibilities in the practice of medicine. Although virtually all physicians in clinical practice encounter situations entailing bad news, medical school offers little formal training in how to discuss bad news with patients and their families."

Eyecare professionals agree that delivering bad news is one of the most important and stressful facets of their job. Preparation and a set of guiding principles are the keys to success.

The following is a course of action that should help to reduce your anxiety and prepare you for addressing your patient:

►First, it is imperative that you are prepared to deliver the news, says Joel Schwartz, M.D., Head of Psychiatry at Abington Memorial Hospital in Pennsylvania. Allot enough time in your schedule for delivering the news and to respond to your patient's concerns. Dr. Schwartz recommends, "Whenever possible, make this the last appointment of the day so that you will be able to give your patient your undivided attention and have fewer chances of interruption."

►Next, have the information you need readily available. Make sure that you are able to present physical evidence to verify your diagnosis.

►Deliver the information as clearly and concisely as possible. Remove as much medical jargon as possible. "Like the essence of giving a good presentation at a meeting," says Martin Mainster, Ph.D., M.D., FRCOphth., Luther L. Fry professor and vice chair at the University of Kansas Medical School in Kansas City. "Worry about whether your audience understands what you are saying. Present things in a concise well-organized fashion."

►Body language is extremely important. Using the proper body language is almost as important as the delivery of your message.

►Recognize the importance of observing a patient's reaction to the news you have delivered. Provide your information in small chunks. Consider taping the session so that you can present the patient with the tape to ensure that he has heard what you have said.

►Once you have delivered the news, it is important that you encourage the patient to ask questions. Find out what the patient already knows about the condition and how much he wants to know.

►Allow your patient to vent. Whether it is anger, sadness or relief, it is very important that your patient be allowed to react to the news. "With the loss of a body part or function such as the eye or vision, there is a well-known response which is very similar to the grief stages in death and dying," says Eddie Kadrmas, M.D., Ph.D., a retina specialist at Post, O'Connor and Kadrmas Eye Centers, PC, Plymouth, Mass. "Understanding this helps us understand the patient and deal with their loss." Dr. Kadrmas says that doctors need to address this loss and realize that patients may follow a pattern similar to Kubler-Ross' stages of death and dying: denial, anger, bargaining, depression and acceptance.

►Be sure to validate the feelings of the patient. "Never say 'I know how you're feeling' because you don't," Dr. Schwartz advises. "Instead say, 'I can only imagine how difficult this is for you.' " This shows the patient that while you cannot walk in his shoes, you are sympathetic to his condition.

►Lastly, have a plan on how to proceed once you have delivered the news.

Three Key Components

Dr. Mainster says that there are three important components to delivering news: (1) Honesty – be frank and complete and never mislead a patient (2) Clarity and Completeness – explain conditions fully in terms a patient can understand. Emphasize the positive as well as negative aspects of a patient's condition. (3) Compassion – Help manage a patient's fear of the unknown. This is often a patient's worst enemy. Discuss their current situation, alternatives and prognosis. Address a patient's potential fears even though he or she may not articulate them. Pay close attention to their body language. It helps you understand how effectively and sympathetically you are communicating with them.

"I don't really differentiate between good news and bad news," said Dr. Mainster. "If patients have been prepared and know what can happen, what can be done about it, and what support is available, then news is just news, good or bad."

Guiding Your Patient

"In order to ensure the smooth flow of patient care, it is important to orchestrate the entire process. Explain the current situation to your patient, ask for questions and then direct your patient to a specialist, if necessary. Send a letter to the primary care physician so that he has a full picture of the care his patient is receiving, and explain the possible need for further diagnostic testing," says Steve Lancaster, O.D., of the Atlantic Eye Institute in Jacksonville, Fla.

His practice also provides personal cell phone numbers to patients in crisis so that the patients know they have access to a doctor 24/7.

Life Changes

An ophthalmologist may frequently find it necessary to deliver information that will cause a patient to make changes that affect the quality of life. For example, imagine delivering the news to an older adult that he may not be able to drive again due to macular degeneration. The loss of driving privileges can be traumatizing. You may feel uncomfortable talking about revoking your patient's driving privileges. In this situation, there appear to be few positive solutions that can be suggested.

"Many times the children of elderly patients will accompany their parents to an appointment and beg us to take away their parent's driving privileges. They fear for both their parent's safety and for the other drivers on the road," says Dr. Lancaster. "Not only do we evaluate the patient's ocular status, we need to do a better job of assessing their lifestyle needs and refer them to other services so that they can receive appropriate care."

"The guiding principal is to treat patients as you wish to be treated; with honesty and compassion," says Melissa Brown, M.D., director of the Center for Value-Based Medicine in Flourtown, Pa. "In severe AMD that most likely will not be helped by treatment, I make sure patients know that they will never go 'blind.' They worry about total darkness and I assure them that will not happen from their illness."

"When I talk about the remanding of driving privileges, be it from cornea problems, cataract, central field defects from stroke or AMD, I say that I understand that they, like many others, might not think their vision is poor enough to preclude driving but that their reduced vision may not allow them to see children darting in front of their car." says Dr. Brown. "Most people can appreciate that and reevaluate their situation." She tries to give patients some time to consider alternatives with their family and emphasizes the importance of contact with support groups, possibly low-vision specialists or public libraries for books on tape, which help keep the patient less dependent on family for all activities. In addition, knowledge of ride opportunities or grocery stores delivery status in the community can help make this life change more tolerable for them.

Another life-changing example is informing a patient of the need for enucleation. Carol L. Shields, M.D., of Wills Eye Hospital in Philadelphia, Pa., says when delivering such news, "A good approach is to always start with something reassuring before presenting bad news. If it concerns a patient's life, there is often no good news to deliver except for the fact that their life may be saved for a period of time with the current treatment. If we are delivering particularly bad news regarding metastatic disease or a threat to life, I have already called the general oncologist, and scheduled an appointment for my patient before walking in and giving them bad news. We enter the room prepared."

Even if a patient needs enucleation of one or both eyes, Dr. Shields says that she always provides available alternatives for her patients so that they can adapt to their future life, such as services for the visually handicapped or other ideas regarding blindness. "We provide patients with books on living with vision in one eye, printed papers on services for the visually handicapped, brochures for eye cancer foundations or foundations that handle visually handicapped people and telephone numbers for appropriate services," says Dr. Shields.

Watch Out for These Pitfalls

When delivering bad news to your patient, avoid the following mistakes:

►Do not be too blunt when delivering your message. You must realize that what you are about to say may very well change this person's life.

►Make sure that you are not choosing an inappropriate time or place to deliver your news. Inform your patient in advance that your consultation may take some extra time and that he may want to arrive with a support system.
Dr. Schwartz warns that with the new HIPAA laws it's essential that only the people that the patient allow, hear or see evidence of the news.

►Most importantly, do not allow the patient to leave the consultation with a sense of hopelessness. "I inform my patients of their condition, explain what to expect in the future and direct them to the next step. Most people appreciate candor, especially if they are a patient that you have an established relationship with," says Dr. Kadrmas. "I always try to be upbeat and never want to send a patient away feeling defeated."

The Need to Educate

Whatever the diagnosis, it is much easier for your patient to digest bad news if you are able to provide useful information and guidelines for them to follow. Offering relevant support system information, Web site addresses or pamphlet information will help to inform your patients and help them to ask educated questions.

"People don't like surprises," says Dr. Mainster. "You need to educate your patients so that they're ready for good or bad occurrences. The truth may not be what patients hope for, but they need to understand and be prepared to deal with it."

Remember, You Are Not the Bad Guy

Giving news that is not positive is difficult. When preparing and delivering bad news to a patient, remember that you are not causing the patient harm; the problem is. Being prepared and well-organized will help you through this difficult task.

Don't Let Bad News Follow You Home

Gale Stoner, professional speaker and author of "Some Assembly Required: Seeing Your Practice Through Your Patients' Eyes" recommends giving yourself 5 to 10 minutes at the end of the day to gather "good listeners" from your staff. Ask them, "What worked and what didn't work for you today?" and let them vent. Then it is your turn. Once you have the opportunity to let off steam and receive some feedback, you can leave your work at the office and go home.

"Some doctors-to-be are 'naturals' and can learn these skills; however there are many others who need to be taught 'bedside manner,'" says Dr. Kadrmas. "I am grateful to the University of North Dakota for preparing me to deal with these types of situations."