Remember Your Wellbeing When Discussing Difficult News

“Difficult news” is any information that negatively affects someone’s expectations for their present or future, or changes their impression of the past. It is anything thought to be hard to talk about or “process” by either the recipient or the messenger of the news.

How difficult news is conveyed can have long lasting impacts

Communication skills have consequences for both patients and doctors. In terms of medical practitioners, how well a doctor discusses difficult news affects:

• their level of personal and professional satisfaction
• ongoing information exchange with patients
• levels of stress and burnout
• time efficiency¹ – communicating difficult news poorly is likely to result in ongoing problems that continually need to be addressed.

Ways to reduce personal challenges

• Take time to identify your own feelings about illness, death, and when you can no longer cure or substantially clinically help a person.
• Explore how these feelings affect how you talk to patients about these topics. You will then be more genuine in your communication with patients.²
• Studies “… have shown that reflecting on one’s own feelings is an essential element in overcoming the tendency to react in non-adaptive ways to patients’ strong emotional reactions in the face of bad news… [making] physicians less likely to use such strategies as giving false hope, providing premature reassurance or offering ineffective therapies”.³
• Acknowledge clinical limitations and remember there is no need for you to “know it all”.⁴
• Take time to prepare yourself for each difficult news conversation.
  
• Consider using Meitar et al’s (2009) “preparatory SPIKES” framework.⁴
• Try to avoid having difficult conversations when you are tired.
• Have another health professional present (with the patient’s consent)⁵ – a colleague can provide support and assistance for both you and the patient.
• After a difficult news discussion, take time to work through your feelings and ensure you are calm before seeing the next patient.
• Also use such time to reflect on the strengths and weaknesses of the conversation you just had to help you improve on the next occasion.
• If possible, talk to other staff about the experience.⁶
• Ensure continuity of care amongst the team about the patient’s emotional issues as well as the clinical ones.⁷
• Enhance communication skills through ongoing training and mentorship.
• Take good care of yourself – try to have an appropriate workload, pursue interests outside of work, take annual leave, take time for professional development and look after your health.
• Seek assistance if you feel the quality of your work is at risk from the demands of your role (see information provided below).

Responding to a sense of failure or guilt

Separate the message from the messenger – remember that the health issue is to blame. Focus on being the best doctor you can be for that person rather than only on successfully treating the condition. If you see your role as purely medical, try to expand your purpose to providing both medical and psychosocial care.⁸

Do not delay for fear of causing grief

It is important to have difficult conversations as soon as practicable. If you wait because of a fear of causing distress, you may lose the opportunity to find out useful information and to provide vital support before a situation worsens. So while doctors may avoid giving bad news to minimise distress, this can leave people “confused, depressed and sometimes angry”.⁶

Are you worried about being wrong?

Early conclusions can lead to inaccuracy, so it is prudent to avoid specific prognosis estimates. If you are confident in the patient’s specific circumstance, use more general terms that are still accurate, e.g. “weeks rather than months” is less likely to cause a future problem than “two weeks”.⁹

If you cannot provide an immediate answer to a patient’s question, undertake to return to the issue when you next see the patient, or refer them to someone who can answer the question. Where necessary, acknowledge that not all questions can be answered, e.g. “The uncertainty must be hard for you, but I’m afraid we just don’t know.”¹⁰

If you find a patient’s question difficult to answer, think about the reason behind the question – it may relate to an underlying issue, e.g. ask the patient “Why do you ask that now?”¹⁰ Reflect on your feelings and expectations about your work, role and medical uncertainty.

Communication skills and self-awareness benefit both you and your patients

Communicating difficult news is a demanding aspect of practising medicine, and you need to strengthen the aspects that you have control over. An important part of this is being aware of your own emotions and taking good care of yourself. This will improve the service you provide and enhance your own wellbeing.
 
Nicole Harvey, MDA National Education Services

Sources of further assistance

• Doctors’ Health Advisory Service:
  ACT 0407 265 414
  NT call the NSW DHAS hotline
  NSW 02 9437 6552
  QLD 07 3833 4352
  SA 08 8366 0250
  VIC 03 9495 6011
  WA 08 9321 3098
• Australian Medical Association Peer Support Service: TAS and VIC call 1300 853 338
• Employee assistance programs (hospital based employees)
• MDA National Doctors for Doctors Program: 1800 011 255

References
1. Back A, Arnold R, Baile W, Tulsky J, Fryer-Edwards K. Approaching Difficult Communication Tasks in Oncology. Cancer J Clin 2005;55(3):164–77. Available at: onlinelibrary.wiley.com/doi/10.3322/canjclin.55.3.164/pdf.
2. Strange Khursandi D. When Bad Things Happen. In: Cyna A, Andrew M, Tan S, Smith A, editors. Handbook of Communication in Anaesthesia and Critical Care. Oxford: Oxford University Press, 2011. p. 143–55.
3. Helft P, Petronio S. Communication Pitfalls with Cancer Patients: “Hit-and-Run” Deliveries of Bad News. J Am Coll Surg 2007;205:807–11.
4. Meitar D, Karnieli-Miller O, Eidelman S. The Impact of Senior Medical Students’ Personal Difficulties on Their Communication Patterns in Breaking Bad News. Acad Med 2009;84(11):1582–94. Available at: journals.lww.com/academicmedicine/fulltext/2009/11000/the_impact_of_senior_medical students_personal.40.aspx.
5. National Breast and Ovarian Cancer Centre. Breaking Bad News. NSW: NBOCC, 2008.
6. Macdonald E. The Doctor’s Perspective. In: Macdonald E, editor. Difficult Conversations in Medicine. Oxford: Oxford University Press, 2004.
7. Fallowfield L, Jenkins V. Communicating Sad, Bad, and Difficult News in Medicine. Lancet 2004;363:312–9.
8. Jackson V, Mack J, Matsuyama R, Lakoma M, Sullivan A, Arnold R, et al. A Qualitative Study of Oncologists’ Approaches to End-of-Life Care. J Palliat Med 2008;11:893–906. Available at: ncbi.nlm.nih.gov/pmc/articles/PMC2998030/.
9. Barnett M. A GP Guide To Breaking Bad News. Practitioner 2004;9 June:392.
10. Faulkner A. ABC of Palliative Care: Communication With Patients, Families, and Other Professionals. BMJ 1998;316:130–2. Available at: bmj.com/content/316/7125/130.full.