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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 2: Communicating Bad News
    A Six Step Protocol

    Step 3. Finding out How Much the Patient Wants to Know Step 4. Sharing the Information

    Step 3. Finding Out How Much the Patient Wants to Know

    Recognizing and Supporting Patient Preferences

    • Each patient has the right to:
      • Decline voluntarily to receive information
      • Designate someone to communicate on his or her behalf
    • People may handle information differently based on:
      • Race
      • Ethnicity
      • Culture
      • Religion
      • Socioeconomic status
      • Age
      • Developmental level
    • Ask the patient and family how they would like to receive information
    • If the patient prefers not to receive critical information, establish to whom information should be given
    • Possible questions include the following:
      • "If this condition turns out to be something serious, do you want to know?"

      • "Would you like me to tell you the full details of your condition? If not, is there somebody else you would like me to talk to?"

      • "Some people really do not want to be told what is wrong with them, but would rather their families be told instead. What do you prefer?"

      • "Do you want me to go over the test results now, and explain exactly what I think is wrong?"

      • "Whom should I talk to about these issues?"
    • For more information, see:

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    Advance Preparation

    • Before actually delivering the bad news it is important to...
      • Conduct an initial assessment
      • Hold subsequent discussions to prepare the patient for critical tests
    • These discussions will provide opportunities to determine...
      • What does the patient know? (step 2)
      • How does the patient handle information? (step 3)

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    When the Family Says "Don’t Tell"

    Professional Responsibility, Family Preferences, and Patient Rights

    • Many times, family members will ask the physician not to tell the patient the diagnosis or other important information
    • In these cases, physicians may feel caught between
      • A legal obligation to obtain informed consent from the patient, and

      • Maintaining a congenial alliance with the family in order to ensure a successful therapeutic relationship
    • Rather than confronting their request with "I have to tell the patient," ask them:
      • "Why do you feel that I shouldn't tell?"

      • What are you afraid I will say"

      • "What are your previous experiences with bad news?"

      • "Is there a personal, cultural, or religious context to your concern, that I should try to understand?"
    • Suggest "Why don't we go to the patient together to ask how much he or she wants to know about his or her health and to what questions there might be."

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    When the Patient is a Child

    • Parents may not want the child told about the illness
    • This protective instinct is understandable, but may ultimately be problematic
      • As the child experiences treatments and procedures, he or she will perceive there is a problem

      • The child may feel distrustful and misled when this happens
    • To avoid this, a better initial plan is to help the parents to understand that this is likely to occur
    • Make a Child Life or Child Psychology staff member available to help the parents and the medical team communicate important medical information to the child at an age-appropriate level

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    Handling difficult cases

    • Some situations may require significant negotiation
    • In particularly difficult cases, support from the institutional ethics committee may be very helpful
    • Ultimately, it may be decided, after discussion with the patient, that details of diagnosis and prognosis and treatment decisions will be discussed only with the family
    • Unless the patient has previously indicated that he or she wants no information, hiding the diagnosis or important information about prognosis or treatment from the patient is neither ethical nor legally acceptable
    • Physicians do not need to feel constrained to practice in a way that compromises care or feels unethical
    • If the physician and the family cannot come to agreement, the physician may choose to withdraw from the case and transfer care to another physician

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    Avoiding Pitfalls

    • There are racial, ethnic, and cultural differences in the preferred handling of information
    • While useful as a background, global conclusions about such differences rarely help with decision-making for an individual
    • Ask a patient about general preferences for the handling of medical information and decision-making early in the clinical relationship before significant information needs to be shared
    • This will help the clinician to avoid making a misstep
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