The Art of Telling Patients Bad News: One Physician's Story

One study found that only about 5 percent of cancer patients had an accurate understanding of their illness. This statistic is likely caused by the way they are told about their diagnosis and prognosis. One physician is sharing his story to bring awareness to the issue.

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The Art of Telling Patients Bad News: One Physician's Story

Difficult conversations are part of healthcare. However, when the news is that a patient is terminal, it might be a bit harder of a conversation than others. One physician found himself on the receiving end of a difficult chat that spurred him to start mentoring other physicians about how to approach telling patients they're dying.

Dr. Ron Naito's Story

Dr. Naito is an internist with over 40 years of experience. When he saw the abnormal results of his blood test, he understood the prognosis. However, when he attended an appointment with his doctor, instead of learning of his formal diagnosis in a compassionate, dignified manner, he was met with attempts to dodge the results. "He simply didn't want to tell me,” Natio said

He told Indian Country Today that at one point, he overheard a specialist discussing the tumor biopsy results with a medical student outside of his exam room door. "They walk by one time, and I can hear [the doctor] say '5 centimeters,’” said Natio. "Then they walk the other way, and I can hear him say, 'Very bad.’” Dr. Naito noted that the shock of this encounter still bothers him. He knew the diagnosis and prognosis because of his years as a physician. However, the lack of compassion, professionalism, and empathy in the way he found out is palpable.

Dr. Naito has been using his time since his diagnosis to help educate medical students at Oregon Health & Science University how to speak to patients when the news isn't good, which isn't a skill many medical or nursing skills teach.

How to Give Bad News

Nurses aren't often the ones who are providing dire test results and terminal diagnoses. However, once the severity of the news wears off and the patient and family has questions, it's often a nurse who sits at the bedside providing answers, education, and support. If you find yourself in the midst of these conversations, here are a few strategies you can use to navigate through:

Show Empathy

Empathy, not sympathy, is one of the most powerful emotions you can offer. Being able to understand and share the feelings of the patient and their loved ones can put you in an excellent position to teach and support them through a difficult time.

Be Honest

These conversations are tough, but glossing over the details doesn't help anyone. Patients deserve the full truth about their diagnosis, expected symptoms, and what the dying process might be like. One study found that only about five percent of cancer patients fully understand their prognosis. Without a thorough understanding of the disease process and what to expect, patients lack the ability to make informed decisions about their care. As a hospice nurse, I quickly learned how to navigate these difficult conversations with truth and compassion. It wasn't always easy, but most patients appreciated the honesty.

Be Open to their Questions

You might not know the answer to some of the questions patients have. Sometimes, you may not even be the best person to give the answer. However, letting them ask the hard questions, and providing support is paramount to your relationship with them. If you don't know the answer, tell them honestly that you'll need to get back to them. Always follow through and get them the information they need.

Don't Use Cliches

It can be very tempting to use phrases like, "just stay strong,” or "it will be okay.” When you are the one receiving devastating news, those words are worthless and even insensitive. Instead, use phrases like, "it's okay to feel this way,” which supports the patient in their feelings.

Show Support

Patients want to know that they have a team of healthcare professionals around them who are there to help. Your job isn't to tell them what to do or what treatment decisions to make, but rather to support them in the decisions that are best for them. Easy ways to show your support can come through your words, but often all you need to do is be present and use active listening skills so that they know you hear them.

After the Bad News

Dr. Naito is sharing his story in hopes of preventing other patients from having the same experience he had. He shared that difficult conversations can be a "heartfelt, deep experience.” We must always remember that our patients are human and have emotions and feelings about their life that we don't understand, so being their support after the bad news is one of the most important places you can be for them.

Have you ever found out a poor prognosis in a less than professional way? If so, tell us about it. Or, have you witnessed one of these conversations and had to navigate through it with the patient and their family? Let us know your thoughts about challenging conversations and how you get through them.

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Melissa Mills

About Melissa Mills, BSN

Workforce Development Columnist

Melissa is a professor, medical writer, and business owner. She has been a nurse for over 20 years and enjoys combining her nursing knowledge and passion for the written word.

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I went for my yearly vision checkup. At my previous visit to the ophthalmologist, I was informed I had creasing of my macula. Truthfully, I didn’t think much of it. Now I was seeing a different doctor. When I mentioned my night vision was deteriorating and floaters were interfering with my vision, the doctor stated in a very off-hand, sarcastic way, “Well, you were diagnosed with macular degeneration.”

I immediately went into fight or flight. I didn’t ask any questions. All I could think of was that I was going blind and why hadn’t the previous doctor bothered to let me know? I think my brain just shut down. All I can remember was that he said to wear sunglasses outside.

It took me ten months to make a follow up appointment to get answers to my many questions. I was still grappling with it. I went to someone highly recommended. After the initial tests, she sat me down. She said “You absolutely do not have macular degeneration and you’re not going blind.” I do need surgery to remove the top layer of my macula, but that will cure my issue. I still want to cry every time I think of it.

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"Bait and switch" with the facts is not uncommon with medical 'professionals'. That is one reason why I go out of my way to deal with my patients and their families in a truthful and honest manner. I hate when this is done to me and I am certainly not going to turn around and do it to someone else.

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I thought my husband had gallbladder issues based on his symptoms. Finally pain was so bad went to ER. After many test the ER doc said “your gallbladder is fine but there are spots on your lungs and liver It might be cancer that’s metastasized so we will have to admit you for work up. No bedside manner at all. EGD showed esophageal cancer and spots were Stage 4 metastasis. Given 1 year. Oncologist came in and gave her spiel in options. Then she said “ so what do you think - you don’t want to hear anymore, you’ve heard enough. You aren’t going to go home and blow your head off are you ? “. In my 35 years as a RN i have never heard anything like it. I am upset I didn’t report her. I was too busy taking care of my husband. He was gone 3 months later.

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Specializes in Nephrology, Cardiology, ER, ICU.

I found out about my cancer diagnosis over the phone while speeding down the highway at 60 mph with my granddaughter in the passenger seat and my phone on speaker of course!

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On 6/24/2019 at 3:12 PM, zbb13 said:

I went for my yearly vision checkup. At my previous visit to the ophthalmologist, I was informed I had creasing of my macula. Truthfully, I didn’t think much of it. Now I was seeing a different doctor. When I mentioned my night vision was deteriorating and floaters were interfering with my vision, the doctor stated in a very off-hand, sarcastic way, “Well, you were diagnosed with macular degeneration.”

I immediately went into fight or flight. I didn’t ask any questions. All I could think of was that I was going blind and why hadn’t the previous doctor bothered to let me know? I think my brain just shut down. All I can remember was that he said to wear sunglasses outside.

It took me ten months to make a follow up appointment to get answers to my many questions. I was still grappling with it. I went to someone highly recommended. After the initial tests, she sat me down. She said “You absolutely do not have macular degeneration and you’re not going blind.” I do need surgery to remove the top layer of my macula, but that will cure my issue. I still want to cry every time I think of it.

You need to let that 2nd doctor know that, apparently, he/she was mistaken. Don't just cry, do something. Just my opinion, of course. You have to handle it the way you find best.

I hope things are going well for you.

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I am a hospice nurse and I can't even add up the times a doctor has given scientific type results to a patient and family, then told them there was someone he wanted them to "talk to". Of course when they see my name tag with "hospice" on it, they get the FIRST realization of prognosis. So sad, awkward, and humbling!! I hardly use the word hospice anymore, and focus on catching patient and family on palliative and comfort measures.

I am in the middle of developing a user friendly card to prompt for a discussion on comfort care for the care givers and nurses to use in their adult care home and facilities, I will include your words if I may!!!

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Specializes in ED, Tele, MedSurg, ADN, Outpatient, LTC, Peds.
On 6/24/2019 at 6:49 PM, Kjorn2 said:

I thought my husband had gallbladder issues based on his symptoms. Finally pain was so bad went to ER. After many test the ER doc said “your gallbladder is fine but there are spots on your lungs and liver It might be cancer that’s metastasized so we will have to admit you for work up. No bedside manner at all. EGD showed esophageal cancer and spots were Stage 4 metastasis. Given 1 year. Oncologist came in and gave her spiel in options. Then she said “ so what do you think - you don’t want to hear anymore, you’ve heard enough. You aren’t going to go home and blow your head off are you ? “. In my 35 years as a RN i have never heard anything like it. I am upset I didn’t report her. I was too busy taking care of my husband. He was gone 3 months later.

That is terrible! I am sorry for your loss. I would report that oncologist. Period!

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Specializes in ED, Tele, MedSurg, ADN, Outpatient, LTC, Peds.
On 6/24/2019 at 8:38 PM, traumaRUs said:

I found out about my cancer diagnosis over the phone while speeding down the highway at 60 mph with my granddaughter in the passenger seat and my phone on speaker of course!

That's a dangerous way to learn about the diagnosis and on speaker phone--.I hope you are fighting the cancer and that you are better now.

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Specializes in Nephrology, Cardiology, ER, ICU.
8 hours ago, spotangel said:

That's a dangerous way to learn about the diagnosis and on speaker phone--.I hope you are fighting the cancer and that you are better now.

Yeah - it wasn't so horrific for me, but my 14 y/o grand-daughter didn't need to hear that.

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On 6/24/2019 at 5:49 PM, Kjorn2 said:

I thought my husband had gallbladder issues based on his symptoms. Finally pain was so bad went to ER. After many test the ER doc said “your gallbladder is fine but there are spots on your lungs and liver It might be cancer that’s metastasized so we will have to admit you for work up. No bedside manner at all. EGD showed esophageal cancer and spots were Stage 4 metastasis. Given 1 year. Oncologist came in and gave her spiel in options. Then she said “ so what do you think - you don’t want to hear anymore, you’ve heard enough. You aren’t going to go home and blow your head off are you ? “. In my 35 years as a RN i have never heard anything like it. I am upset I didn’t report her. I was too busy taking care of my husband. He was gone 3 months later.

Condolences.

On 6/24/2019 at 7:38 PM, traumaRUs said:

I found out about my cancer diagnosis over the phone while speeding down the highway at 60 mph with my granddaughter in the passenger seat and my phone on speaker of course!

Hope you're doing better. I would have had to pull over quick.

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Specializes in LTC, assisted living, med-surg, psych.
On 6/24/2019 at 3:49 PM, Kjorn2 said:

I thought my husband had gallbladder issues based on his symptoms. Finally pain was so bad went to ER. After many test the ER doc said “your gallbladder is fine but there are spots on your lungs and liver It might be cancer that’s metastasized so we will have to admit you for work up. No bedside manner at all. EGD showed esophageal cancer and spots were Stage 4 metastasis. Given 1 year. Oncologist came in and gave her spiel in options. Then she said “ so what do you think - you don’t want to hear anymore, you’ve heard enough. You aren’t going to go home and blow your head off are you ? “. In my 35 years as a RN I have never heard anything like it. I am upset I didn’t report her. I was too busy taking care of my husband. He was gone 3 months later.

Oh my Lord. My husband and I had practically the same experience when he was abruptly diagnosed with cancer eight years ago. I’d taken him to the ER to get his gallbladder checked because he had what seemed like a textbook case of cholecystitis. After a CT scan and us having waited hours for results, the ER doctor walked in stone-faced and said in a monotone voice, “Well, you’ve got tumors in your liver and pancreas that don’t look good. I’m going to admit you for more tests.” Then he walked back out without saying another word—not an “I’m sorry” or even an explanation of the shattering news he’d just given us. I was a working RN at the time, but in this case I was just another frightened, devastated wife of a man who was now dying of cancer. 
 

Fortunately we saw other doctors during that hospitalization who were compassionate and genuinely sorry about the results of their tests: stage IV pancreatic cancer with liver mets, with a prognosis of 3-6 months. We got three blessed years, and most of that time was good. But I’ll never forget that ER physician who was so cold and unfeeling at a time when we’d just got the shock of a lifetime. I don’t expect healthcare providers to dissolve in tears when they have to give a patient bad news, but a gentle hand and a sincere expression of condolence is much appreciated.

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