AANS Neurosurgeon | Volume 28, Number 4, 2019

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Delivering Bad News to Patients

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We have all been there — rehearsing the impending conversation in our heads before entering a room full of people we have either never met or only met briefly in clinic. Furthermore, I imagine we can all remember the emotionally draining process of learning how to handle these meaningful discussions.  Lastly, many of us probably recall very specific cases that were particularly distressing. Delivering challenging information is an important and inherent aspect of most neurosurgical practices. The reason it may be difficult arises out of a variety of factors.  

Effective Communication is Critical
Neurosurgeons realize that often times the message to be delivered will be bad news. This challenging, yet essential process, can be taxing for all involved. In contrast, the information itself may be complex and challenging to convey in an understandable manner. The factual details being relayed to a patient or family may be technically complicated (i.e., mechanisms of secondary brain injury), it may be inexact (such as early prognostication of outcome after intracranial hemorrhage) or it may be evolving over a longer period of time necessitating multiple interactions for adequate explanation (as in progression of disability associated with cancer over time from diagnosis to terminal stage).

The actual dissemination of information is impacted by the level of confidence of the practitioner, the ability of the patient or family to understand the information being presented, the environment within which the information is delivered and the stress of acute illness and/or the family dynamics of those being counseled. There are other medical subspecialties that understand how this can be difficult — it is not unique to neurosurgeons. However, neurosurgeons are certainly in the club of those professionals who need to know how to do this with grace and dignity. Not many medical subspecialties combine the complexity of pathology, physiology, anatomy and prognostication with suddenly disastrous and dramatic injuries.
 
Understanding how to effectively communicate with patients and their families is critical to counseling them. Knowledge that took neurosurgeons years to accrue must now be boiled down to its most basic components in order for a layperson to understand. We carefully balance explaining the disease condition, treatment options and how each treatment (or non-treatment) will be expected to impact the patient over time. Effective communicators need to be able to adjust their presentation, including the amount of information imparted, to the needs and abilities of the audience at the time of information delivery. For example, providing a patient with a cancer diagnosis requires personal attributes that can be hard to muster during a busy day — patience, tact and compassion. It also requires attributes that should be at the forefront of the practitioner’s repertoire every day — knowledge, competence and dedication to helping others.

Call for Patience, Compassion and Support
Medical education continues to teach that often in the immediate aftermath of hearing certain words or phrases (such as “cancer” or “dead”) patients or their surrogates often fail to hear anything else that follows. It would seem that our cumulative practical experience most often reinforces this teaching. Patience is required to offer time for the patient or their family to process the information that has already been given before moving the conversation onward to cover other things. In fact, many times it is advisable to deliver the information that is needed immediately by itself and to schedule a planned return to review what has already been disclosed and to then proceed with any new information.

Neurosurgeons are also called upon to be compassionate in their care and to show the same type of compassion towards the patient or family in helping them understand and accept a new or progressive diagnosis. Most neurosurgeons have the opportunity to see patients with a variety of disabilities that principally arise from the progression of disease. These disabilities include a very diverse taxonomy of problems including chronic pain, weakness, sensory disturbance, language and cognitive disturbance. While most neurosurgeons do not have to live with these specific disabilities themselves, our collective exposure to patients with different challenges gives us a relatively unique opportunity to counsel patients on how others have dealt with similar problems and also allows us to act as one source of support for patients as they work to cope with the evolution of symptoms or problems over time.

There is some guidance in the literature regarding considerations for such conversations. One example is from a Dr. Buckman who proposed the acronym SPIKES (readers are encouraged to read the article as well as others listed as references): Setting, Perception, Invitation, Knowledge, Empathy, Summary and Strategy. Some of his advice includes ensuring the setting is appropriate for the conversation (quiet, private, etc.).

The Impact on Patient and Provider
Additionally, it is helpful to brace the patient or family for the fact that the conversation will be difficult to understand and manage. Those with skill in this area will next get a feeling for their perception of the case to date.  Find out what the patient or family already understands and what questions they may have.  As the conversation evolves, speak as definitively and unambiguously as possible. You do not want the patient or his or her surrogate to struggle to figure out what you are really trying to say. Intermittently, make sure to stop and ascertain whether the audience understands each layer of the conversation. Finally, attempt to summarize the conversation from both your perspective and what you feel is their viewpoint.  This helps to ensure that everyone ends up on the same page. Once you are comfortable that there is some common ground, a plan of action for moving forward can be outlined. 

Delivering bad — or worse — often devastating news, and its impact on patient and provider, is not something we frequently talk about or acknowledge in our profession. There are likely several reasons for this, not the least of which is that we know all too well how taxing it is. Sometimes, neurosurgical practice seems to be almost defined by tragedy, disability and death, and probably appropriately we want to avoid thinking about it more than necessary. Some of us may want to suppress these memories and emotions until the next time that skill set is needed in practice.

Resultantly, we develop strategies and/or defense mechanisms to protect our own psyches. Despite the toll that imparting bad news and caring for critically ill patients takes on us as individual practitioners, it seems indisputable that the responsibility to care for our patients includes the additional, vitally-important responsibility we have to provide them with honest and empathic, even if difficult, information about their diagnosis or condition.

References

1. Creagan E. “How to Break Bad News – and Not Devastate the Patient” in Mayo Clin Proc 69 (1994):1015-1017.

2. Baile, Walter F., et al. “SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer.” The Oncologist 5.4 (2000): 302-311.

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