When You Have to Break Bad News

A hands-on program helps clinicians avoid being a ‘Google Doc.’

A bad experience with an uncaring or distracted clinician can be nearly as harmful to patients and their families as a dire prognosis, according to Anthony J. Orsini, DO, a neonatal and perinatal physician from Orlando, FL. Dr. Orsini is the creator of the Breaking Bad News (BBN) program, a training program that helps healthcare professionals improve compassionate communication with patients and their families. Dr. Orsini was a guest speaker at the recent iaedp symposium in Orlando, FL. 

Dr. Orsini explained that only about 10% of physicians have any formal training in dealing with delivering bad news to families, and most feel unprepared for and even fearful of this challenge. Part of the hesitation and fear involves anxiety about making mistakes or being misunderstood. He noted that police officers actually have more training than doctors about how to compassionately communicate with families when a loved one has a crisis, and the prognosis is poor.

Dr. Orsini developed the BBN course to help change this. In the program, healthcare professionals participate in improvisional training sessions with professional actors. The sessions are videotaped and watched remotely by a panel of trained physicians and non-medical instructors. The participants then watch the videotapes of their sessions with the physicians and instructors. Over the past 5 years, more than 600 residents and physicians and practitioners in many specialties have been trained; this year, 120 healthcare professionals in 5 states are scheduled for BBN training. 

Changing a long-time culture of neutrality

Dr. Orsini noted that from the turn of the last century and until recent times, clinicians have been taught to be neutral or detached when dealing with families in crisis. From the original model of doctors as comforters, the modern direction  has been to be more detached and scientific. There are many reasons for this, including a lack teachers and role models, and mostly, a lack of training in delivering bad news. A lack of compassionate communication then leads to mixed messages. Dr. Orsini pointed out that just as W. C. Fields said, “It’s all in the delivery.”

Dr. Orsini also advised the audience members to avoid being what he called a “Google Doc,” or a clinician who is excellent at delivering information only. The meeting with family and patients is not all about providing information, he said, but instead is about forging a trusting relationship with the health care team, including doctors, nurses, and nurse practitioners. Not doing so can harm the patient and family, lead to anger, or even to a lawsuit, he added.

Better ways to communicate bad news

Dr. Orsini also gave a number of tips about better communication in crisis situations. Unlike previous years when the emphasis was on science and new medical techniques, today’s patient demands a relationship with the clinician, he said. When you must deliver bad news or a poor prognosis, the clinician needs to position herself or himself for success from the moment he or she walks into the room, he added. In what he calls the “bracing moment,” Dr. Orsini offered advice about starting a difficult conversation. One way to accomplish this in a compassionate way is to begin the conversation with a review of the situation so far, establishing what the family and patient understand. One suggested way to start the conversation is to say, “Tell me your understanding of what is going on,” Dr. Orsini said. He advised the audience to work on their observation skills, remembering that they are being observed as well. Our brains make 300,000 to 1 million observations per second, but the brain can’t make 2 analyses at a time, he said. Seventy percent of all language is nonverbal, he added.

Clinicians’ body language matters

Body language is a large part of the process, he said, and even the way a clinician takes a seat in the conference room can be important. It helps to think of the meeting as a “chat” with family members, and not to assume a pose or posture. Two helpful actions that can make a big difference are to keep the hands above the table and to be seated close enough to the family members to reach out a comforting hand when needed. Crossed legs and crossed arms can “push away” family members, so an open and trusting stance is much better, he said. Verbal and nonverbal communications should match; when they do not, confusion, anger, and mistrust can occur.

Dr. Orsini also advised avoiding “blindsiding” patients with the bad news, and instead to gradually break the news, using terms such as “I am concerned, or “I am worried that you might also be concerned,” and then to compassionately communicate a combination of knowledge and concern about what has happened. Sometimes silence can be a powerful tool, too, he said, particularly when the family members may be stunned and silent at the bad news.  A rabbi once told him that in such situations it is best to “just say you are sorry and shut up,” he said. 

Finally, Dr. Orsini stressed the importance of being specific about what is next for the patient and family, and to manage the conversation. The goal here is to help the family avoid feeling abandoned, he said. Some ways to do this include offering to meet with them at a later time, to follow up with your business card or telephone number, and to assure them that you are going to help them get through this rough stage.

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