The delivery of bad news to a patient about a new cancer diagnosis or another illness with a particularly poor prognosis can lead to lasting negative effects on the patient and their families. This can irreversibly damage the doctor-patient relationship. Physicians have a duty to be honest with their patients while making them feel safe and reassured.
Health care professionals admit that breaking bad news to families of hospitalised patients is one of the most difficult tasks yet family decisions largely depend on the adequacy of this initial communication. Dr Sharon Nasuuna, the lead doctor accidents and emergency at International Hospital Kampala (IHK), says effective communication of bad news is key to both the healthcare professional and the recipients.
The bad news healthcare professionals communicate ranges from death announcements, issuance of negative health test results such as various types of cancer, among other health scares, accidents and their counter-effects such as amputation, among others. The bad news normally shared is death of a patient, permanent incapacitation, terminal illnesses, incurable diseases and livelihood wrecking diagnoses.
Dr Nasuuna explains that decisions about treatment options and future planning depend so much on this communication, stressing that families are often distressed during this time. In her experience, Dr Nasuuna says, the recipients of the bad news [patients and caregivers] experience a state of denial while others struggle to accept the news.
“In some cases, some take the blame or blame others for the incidents leading to bad news,” she explains.
Patient-centred communication in Uganda is perceived to be poor. In 2015, Uganda introduced Patient-centred care (PCC) as a concept to improve quality of care. Dr Nasuuna explains that institutions need to first of all have a communication strategy aimed at announcing the bad news.
“Any bad news will lead to an array of emotions and reactions from the recipient, which in some cases might also affect the recipient’s health. We see people faint, throw tantrums, and cry among other expressions,” she says.
How the bad news is communicated, she says, has a big impact on their mental health, how they manage the situation and inevitably, how they relate with the health centre. She adds that misinformation or poor communication leads to future challenges such as biases within the circle of the affected person, the reputation of the caregiver and or the health centre.
“We see this happen more often these days because of social media where fake news happens to thrive. So, yes, a communication strategy is important in our line of work,” she says.
On top of having a plan in place, aao.org, an online portal, states that there are general strategies that must be adopted in order to enhance the delivery of bad news.
In medical school, Dr Nasuuna says, there is a module on how to deliver bad news, which takes into consideration tone, ambience, how to position oneself, how much to communicate and at what time, how much time the recipients need, and so much more.
When it is time to communicate the bad news, the healthcare professional should be aware of the family’s knowledge and reactions. If necessary, she says, a support person should be available during the discussion. If it is a team involved, a decision should be made in advance.
Since discussions regarding confidential information about patients must be conducted using a “face to face” approach, privacy must be ensured.
Dr Nasuuna explains that at IHK, there is a dedicated meeting room (boardroom) where family members are directed to ensure privacy. She says the reason behind a private location is to help healthcare workers to demonstrate empathy, compassion and sincerity. This kind of setting also allows provision of additional information and support, if needed. She explains that families can also easily open up.
A comprehensive discussion of the patient’s test results, diagnosis, and prognosis may be time-consuming, depending on the complexity of the news and preparedness of the family. She suggests a mutually convenient time of the day for all parties that allows sufficient time without interruptions.
“We do not attach particular time to this because you might find a family that is struggling too much so there is nothing like going to deliver the news in 10 minutes. We give them all the time in the world. If they still have questions, we have to be there to answer them. We only leave when most parties feel satisfied,” she says, adding that they also practice patience with those receiving the bad news, answer their questions and do not change statements. Medical personnel also extend psycho-therapy services to the families to help them cope with the news.
It is important that the message is honest, reliable and communicated in unsophisticated language because families may be too intimidated to ask for clarification.
“We do not use medical jargon. We use lay language. If they are speaking English, we speak English, if they use Luganda, we speak Luganda. If they speak Chinese or any other language, we have facilities to deal with interpretation. We break it down to the smallest detail,” she says.
Healthcare professionals should at all times show a caring attitude to the family and patients.
Dr Nasuuna says: “Support depends on the situation at hand. We have to decide whether we assist them with clearance of the charges, giving them seniority because that is what some people want, attend the burial, requiem mass or vigil in certain cases. All this depends on the gravity of the situation coupled with other factors.”
Build a relationship
Sometimes you might be tasked with delivering bad news to a patient or a family member you have only met minutes prior. However, there is no substitute for building a foundation of trust.
Bonding with a stranger is something we have to do with every new patient. How do you ask someone you have never met to trust you with their life? First impressions matter. Take these things into consideration; how you dress, how you speak, what your body language is saying, how you move about the room, how your staff interacts with you. Trust is hard-fought and well earned. It is the foundation of a healthy doctor-patient relationship.
Learn about your patient
You will want to know the patient as much as you can beforehand:
● Review their chart, medical record, and scans BEFORE you enter the room.
● Memorise all of the pertinent facts.
● Do not type on your computer or ruffle through papers in front of them.
Make the patient feel special
Even if you have a very busy clinic, make every patient feel that they are your only patient that day. Schedule a longer appointment to allow ample time for discussion. By providing a generous appointment window, you give yourself time to learn your patient’s preferred method of communication and a good deal of their personality.
Engage with the family
Introduce yourself to the patient and everyone in the room. Take a moment to learn their names and relationships.
Initially, avoid using humour or touch to establish a relationship with patients or family members with whom you are not yet familiar. You may do so as the encounter progresses based on cues you observe from the patient and their family.