Midlevel U.
The Rules for Delivering Bad News to Patients
August 27, 2019
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I've talked to some colleagues recently who've been a little down about their roles as nurse practitioners. Working in family practice, they have found themselves in the position of delivering bad or upsetting news to their patients. Cancer diagnoses were fortunately made rather than missed, but letting a patient know they've got a serious, life-altering illness or condition is tough, not to mention, this is not something most of us as NPs learn to do in school.
Have you ever found yourself in the position of delivering difficult news to patients? How did you feel? Having such conversations as nurse practitioners can make us anxious or awkward. Some of us approach these discussions emotionally while others appear detached and robotic in their delivery of the news. Delivering bad news is an unavoidable part of our jobs as nurse practitioners but that doesn't mean we get used to it. Fortunately, however, conducting serious conversations is a skill that can be learned and there are many guidelines out there to help healthcare providers hone this skill set.
Rule #1: Know what constitutes bad news
Sometimes I share information with a patient that I perceive as not a big deal. Then, the patient starts to freak out. Or cry. Or to have some other sort of emotional reaction that I didn't anticipate. Bad news doesn't have to be a terminal diagnosis. It can be related to anything surrounding a diagnosis such as timing, personal or professional consequences. Breaking a metatarsal and wearing a boot, for example, may not be too bad in the grand scheme of things, but breaking your foot the day before your wedding is pretty disappointing.
Rule #2: Full disclosure is best 
In the past, healthcare providers operated on a more guarded front. In the 1800's, for example, the American Medical Association even encouraged physicians to avoid sharing news that discouraged patients. Today, however, studies (not to mention ethics!) show that most patients prefer full disclosure. It's our duty as nurse practitioners to share up-front, honest information rather than sugar coat our delivery with excessive optimism, withhold details, or give false hope. Share news with the patient directly rather than directing it toward family members. Honest, trustworthy information is empowering!
Rule #3: Prepare yourself
Anticipate the conversation you're about to have with your patient. You may even wish to practice your delivery with a colleague. Prepare yourself to feely badly as you share the news. And, don't forget that silence is OK. Avoid the temptation to fill gaps in your conversation rather let the patient process and take the time to formulate questions.
Rule #4: Frame the conversation
Framing the news you're about to share is essential. Your patient may or may not be expecting to hear something difficult. And, the way you set up your conversation has an impact on the patient's reaction. Using the word "serious" (ex. "I have some serious news to share...") is better than using the word "bad". "Serious" creates a more constructive framework that inspires action and empowerment as opposed to the word "bad" which indicates the situation is helpless. Even if you're delivering a terminal diagnosis, your patient can choose how to react and what steps they wish to take in response.
Rule #5: Think SPIKES
There are a few well-known methods for delivering serious news to patients, my favorite of which is the SPIKES method. This algorithm lays out considerations for nurse practitioners and other healthcare providers in these situations. Here's the SPIKES protocol:
Setup - Think through the conversation you're about to have, anticipating questions the patient might ask beforehand. Prepare for an emotional reaction. Gather any necessary resources that might be helpful for the patient.
Perception - Gauge the patient's understanding and perspective on the news you have shared. This is best accomplished by asking questions like "What did you take away from what I just shared with you?" or "What are your expectations of treatment?". This way you know you are both on the same page as far as understanding the medical outlook, next steps and goals.
Invitation - Encourage the patient to think further about their care going forward. Find out how much information the patient wants about his or her medical condition as well as who he/she would like to be included in decision making such as family members.
Knowledge - This step has to do with how you as a provider deliver information. The best practice is to deliver the headline first, followed by the details. Communicate using language that matches the patient's level of education and medical knowledge. Be direct in your delivery, avoid skirting the main message.
Empathy - Understandably, patients get emotional about serious news. Anticipate such a reaction and display empathy. Naming the patient's emotions can help. Asking "Can you tell me more about what you mean by that?" will also help you determine how the patient feels about the situation.
Summarize and Strategize - Make a plan for the next steps in both treatment and communication with your patient. Express support and encourage the patient to tell friends and family the news to develop a personal support system. Talk about how the patient can act on this news to accomplish his or her treatment and lifestyle goals going forward.
Have you ever delivered bad news to a patient? How did it go?
