Break Bad News Better
We talked to a glaucoma patient — and patient advocate — who offers advice on how to deliver a disturbing diagnosis with compassion.
By John M. King, Senior Associate Editor

"I'm sorry. You have glaucoma. We can start you on medication and you can have surgery, and then you still might go blind."

This is how Edith Marks, a former trainer of special education teachers in New York City, learned her diagnosis. Accurate? Straightforward? Yes, Mrs. Marks says . Helpful? Supportive? Not so much, she says.

Looking back at her experience, and after having researched her disease and talked to experts in medicine and science, as well as caregivers, family members and patients, Mrs. Marks co-authored a guide for patients "Coping With Glaucoma" (Avery Publishing Group). An active senior, she attends ophthalmology conferences and often speaks to groups of medical professionals. Here are her suggestions for physicians in this unenviable position.

1. Strength in numbers. If you think a visit might result in bad news for a patient, recommend that he bring along a spouse, friend or family member. When people hear bad news, they're often still trying to digest it while you're explaining the diagnosis and treatment options. When they leave your office, they probably won't remember part of what you told them, but their companion can fill them in and answer questions later.

2. Be tactful. While this may seem obvious, remember that tact doesn't come naturally to everyone. To make sure your words and delivery are sensitive, you might "rehearse" in advance in front of a colleague. Always be mindful of the major impact your words as a physician will have on patients. A caring delivery sets the tone for a person's attitude about his diagnosis and treatment.

3. Exude confidence. When patients are in a vulnerable position — possibly reeling from bad news — it's comforting for them to feel confident in their doctor. If you waver, they'll sense it. If you project confidence in your abilities to help them, they'll be confident in you, too, and they'll be more receptive and enthusiastic about treatment. Be conscious of your demeanor: A doctor's long face or negative body language says, "We won't be able to do much for you."

4. Show an upside. Often a diagnosis that sounds like bad news can have an encouraging prognosis. Other times, there's little you can do to help your patient's vision. Whichever type of case you're dealing with, it's very important to include some encouraging information when you break the news. Try, "Here's the situation, but we're moving ahead very fast, refining techniques and developing medications for this problem." Remember point #2 and make sure you are talking to the patient from a position of confidence.

5. Explain everything completely. Mrs. Marks recalls a woman in a glaucoma support group once complained: "My doctor doesn't tell me anything. He doesn't tell me what's going on with my eye." This patient had cataract and glaucoma surgery; when she emerged seeing nothing, her doctor told her she needed another procedure. Without being adequately prepared for the
consequences of her surgery, she lost confidence in her doctor.

It's true that some people don't want to know everything, but it's best to assume they do. Don't decide just because someone is old or upset that she doesn't want the details, including the diagnosis and treatment strategies. A detailed explanation of a procedure often isn't as frightening as what the patient may be imagining. "He's going to put a knife in my eye" is a much more frightening thought than the reality of the surgical experience. If you explain what's going to happen, patients will be more relaxed, confident and cooperative.

6. Avoid assigning blame. People make lifestyle choices that affect their vision, and, of course, age and heredity determine many problems. But none of this is the patient's fault. Make sure they understand this. Mrs. Marks recalls a doctor who felt frustrated every time a new medication didn't work for her. Unfortunately, his attitude made her feel guilty, so much so, that she eventually found a new doctor.

7. Remember to listen. Patients want to feel taken care of. Even if you deliver the same news to many patients, keep in mind that each one is an individual. Each patient has a different life, so the impact of the diagnosis will vary, and so will the patient's questions.

8. Help patients help themselves. If you tell patients what lifestyle changes they can make and how they can learn more about their problem, they'll feel more confident and in control of the situation. They'll learn more and try harder.

9. Offer support. Recommend a support group for your patients. Patients are comforted to find others with the same concerns and to get suggestions about dealing with their vision problem. Doctors should be an active, vital part of patient support, periodically attending support groups to answer patients' questions. In the case of glaucoma, I recommend that doctors start support groups to educate their patients.

10. Guide patients toward learning more. Patients will have questions, so be sure to have facts on hand, even about topics like taking vitamins. Not only does it help to have pamphlets, but it's also a great help to recommend books for patients with certain health problems. Books written from a patient's perspective can offer the same kind of comfort and information as a support group.

11. Recommend a second opinion. After delivering bad news, offer to help your patients get a second opinion. Generally, patients would prefer that you recommend another doctor and pass their file along. If you don't make the offer, the patient often will get a second opinion and hide it from you. You'll both benefit from your gracious attitude.

12. Call the next day. Many dentists have a policy of making follow-up phone calls the day after a major procedure. You should do the same the day after delivering bad news. The call is reassuring, inspires confidence in you and gives patients the opportunity to ask questions that come to them after they leave your office.

It's all in your delivery

Being the bearer of bad news is never easy. But polishing your delivery skills can make all the difference between a distraught patient and a patient who has the courage and confidence to face what's ahead. With your sensitivity and preparation, your patients will find bad news much easier to take.