In Practice: Dealing With Death

Do you get sweaty palms whenever you have to deliver bad news to a patient?

Consider yourself lucky. It’s when you feel no anxiety while telling a patient her biopsy is positive, or that her cancer isn’t responding to treatment that you should worry about yourself. But while it’s natural to be uneasy, being incompetent at communicating difficult, even heartbreaking, news isn’t really excusable. It could be the difference between comforting a seriously ill patient or just making matters worse.

You only get one shot at giving a patient bad news. You have to know how to do it right.

“If you do it well, you’ve probably helped the patient and family through an extremely difficult transition,” says Jerry Old, a Kansas City-area family physician and hospice director, says. “If you do it poorly there will be bitter memories for a long time and it could make the grieving process worse.”

Old, who lectures at the University of Kansas School of Medicine in addition to directing Hospice Care of Kansas, says the rapid aging of the U.S. population adds urgency for physicians to learn how to discuss death and dying with patients.

“Eighty-five and up is the fastest-growing segment of the population, but life is finite and the mortality rate is 100 percent so we are going to be dealing with a lot more end-of-life issues very soon,” he says.

Old points out that improving one’s skills in communicating bad news can have a practical side effect: patient and physician satisfaction tend to go up when physicians move smoothly from the curative to the palliative approach.

“If you can make that transition, you won’t blame yourself or feel like a failure when the patient does die,” Old says. “You’ll feel like you helped, and that’s the satisfaction of practicing medicine.”

Do the seven steps

Although physicians can find a growing array of articles, continuing medical education seminars, manuals, workshops, and even fellowships in palliative care, many still don’t know how to support dying patients properly.

David I. Wollner, a New York City physician trained in geriatrics and oncology, says it doesn’t take extensive training to communicate well and show empathy.

“Put the same kind of energy into that training as you’d put into learning something like a cardiac catheterization. You’ll get to where you can do it well every time,” says Wollner, who is director of palliative care for the Metropolitan Jewish Health System in New York City.

Wollner recommends a seven-step communication process outlined nearly 10 years ago by the Educating Physicians in End of Life Care (EPEC) project. The project - an effort by the American Medical Association and the Robert Wood Johnson Foundation - suggests that physicians approach patients to whom they must give bad news by:

• Preparing. Choose a quiet, comfortable location where there will be no interruptions, turn off pagers and phones, and decide - asking the patient, if possible - who else should be in on the discussion. Adds Wollner, “Make sure you truly know all of the medical details of the patient’s case beforehand.”

• Assessing. Find out what the patient already knows and wants to know. “Some people want every laboratory test, every fact you can give them, while others, often the elderly from other cultures, may say, ‘You’re the doctor, you decide’ or ‘Talk to my son or daughter,’” Wollner says.

• Warning. Old calls this “firing a warning shot.” It is simply saying, “I have some bad news.”

• Describing. Present the facts of the case in a succinct but caring way and in terms that patients with no medical background will easily understand. Don’t talk for too long, suggests Thomas McCormick, a medical ethicist at the University of Washington School of Medicine in Seattle. “After you say a word like ‘cancer’ they aren’t going to hear much of what comes after that,” he says.

• Pausing. Sit quietly until the patient responds to the news. How long should you wait? It may feel like an eternity to you but imagine what it feels like for the patient, says Old. If there is no response he suggests asking, “Can you tell me what you are thinking about?”

• Validating. In addition to assessing the patient’s emotional response and answering questions, try to empathize with the feelings expressed. When answering questions, give the information in small chunks, Old says.

• Planning. Always end the discussion by presenting a follow-up plan. This can be as simple as setting up another discussion later in the day. “You want to ensure continuity of care for the patient, give a clear picture of the next steps, and make sure somebody is around to answer questions,” Wollner says.

What about you?

Michael Fisch knew exactly when his work with dying patients was beginning to affect him personally. Fisch, an associate professor of gastrointestinal medical oncology at M.D. Anderson Medical Center in Houston, says the revelation came soon after his mother had developed the lung cancer that eventually killed her. He recalled talking at length with her to answer several detailed questions but did not feel any emotion during or after the conversation.

“I realized that when I got into my clinician role, emotion disappeared for me, and it was the sign of an over-tightened emotional spigot,” he says.

Fisch cautions other physicians who work with patients who are seriously ill to:

• Be alert for changes in their own feelings or reactions when giving bad news;

• Acknowledge when they might be feeling too little or too much emotion; and

• Work through their issues by attending communications workshops that involve role-playing and observation by colleagues and trainers.

Sometimes, it may be more comforting to seek support and feedback from distant colleagues rather than those with whom you work daily, he says.

“You have to be able to quiet your own voices,” McCormick says. “If you want to run out of the room, you’re thinking too much about yourself and you’re not going to be much help to the patient."

”For that very reason, Old says it is common to see physicians erect mental and emotional barriers to avoid getting too involved in a patient’s care. “A balance is needed and it’s sometimes very hard to find,” he says.

Wollner says it is important for physicians to find a safe place or “safe” colleagues with whom they can discuss emotions.

“There have to be sanctioned areas - clearly designated places you can go to piss and moan, talk about it, try and work through it,” he says.

McCormick recommends that physicians embrace a dual role - as both curative and palliative care providers rather than one or the other. That way, they will never feel that they abandoned the dying patient.

“When the medications don’t work anymore you can still have something to offer patients instead of just stopping your care and turning them over to the hospice people,” he says.

Family matters

Physicians may sometimes feel that they spend as much or more time talking to and counseling family members than they do the seriously ill patient.

“It wasn’t an obvious point to many physicians, even five years ago, but the family is part of your targeted care,” says Fisch. “The responsibilities for informing them may not be the same as the patient’s but including the family in the process of caring for the patient in the most appropriate way is a key point.”

Families can be harder to deal with, Old says. But taking a team approach that includes nurse practitioners, social workers, chaplains, and other professionals may help ease tensions, he says. Family interference that leads to serious patient noncompliance is talked about far more often than it actually occurs, Wollner says.

“We do ourselves a disservice by imagining that families are going to be the cause of noncompliance,” he says. “I’ve never seen a multidisciplinary team approach that’s planned and rehearsed not work or at least get the discussion started about these very sticky and difficult end-of-life issues.”

Culture connection

While many Americans approach healthcare decisions - including life and death issues - head-on, other cultures may take a different tact.

Individuals from some cultures feel that talking about death and illness depresses the patient’s resolve or will lead to additional illness. Others may believe that news of a serious illness will make other family members vulnerable to repercussions and even discrimination. Many cultures cede major health decisions to certain family members. With dozens of cultures represented by millions of recent immigrants to the U.S., how can a physician know which norms to keep in mind when breaking bad news?

Just ask, McCormick says.

“By admitting to the patient that you don’t know a lot about their culture or how they prefer to discuss health issues, you open the door for them to tell you what they want,” he says.

Where to train

Telling someone they’ve taken a turn for the worse and may not live much longer is a difficult discussion to initiate. Training helps but many of today’s practicing physicians never got the chance to learn the necessary communication skills while in medical school.

“I went to school in the 1970s and we were not trained well in things like pain management or end-of-life issues,” Old says. “I remember the first time I had to tell a family somebody had died. I didn’t know how to do it and I didn’t do it very well.”

Although more medical schools now include communication skills and other training about palliative care, many medical schools seem to give the issues little more than lip service, says Jay Bhatt, president of the American Medical Student Association.

“At a lot of schools there’s very little dedicated instruction or skills training in delivering bad news,” says Bhatt, who is scheduled to graduate from the Philadelphia College of Osteopathic Medicine in June 2007. “You kind of read about it and come across it in a geriatrics rotation or some other rotation.

”Bhatt, 29, says having more life experience than his fellow students helped boost his confidence in discussing end-of-life issues with patients and families. Often, however, there is too little time for students to pause during rounds with physicians to listen in on and learn from these discussions, he says.

“If you haven’t had that experience in life, or even in a mock setting or through instruction, you’re going to be in a really bad place as an attending physician or resident,” he says.

Becoming a compassionate communicator is no longer another nice addition to the physician’s beside manner; it’s becoming an essential tool, says Fisch.

“With the new awareness of these issues throughout society, the bar has been raised,” he says. “The public expects physicians to do this type of communication and do it well.”

Practicing physicians can find information about end-of-life care communications issues on the Internet or medical specialty society scientific meetings.

Old says the American Academy of Family Physicians recently moved his lecture about palliative and hospice care from a breakout session to a featured lecture at its Scientific Assembly. In previous years, he felt he had to disguise his lectures as “pain management” to draw listeners.

While organized medicine, medical institutions, and individual physicians are starting to recognize the importance of end-of-life issues, it may take a grassroots effort to convince another key player - the federal government - to support more research and physician training.

“Caring for the sick and dying is as important as inventing or finding cures for the young and living,” Wollner says.

Bob Redling has written on practice management topics for more than nine years. He has been practice management editor for Physicians Practice, Web content editor and senior writer for the Medical Group Management Association, and a speechwriter for the American Academy of Family Physicians. His work has been published in Physicians Practice and MGMA Connexion. He also was a government affairs reporter for United Press International. He can be reached via editor@physicianspractice.com.

This article originally appeared in the February 2007 issue of Physicians Practice.