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by
Doug Knutson and Doug Post
Department of Family Medicine
The Ohio State University
The Ohio State University medical school curriculum includes a two-year course titled “Patient Centered Medicine.” The course is structured around different content areas, such as ethics, palliative medicine, professionalism, violence, sexuality, addiction, etc., and is a mix of lectures and small group sessions. This case has been used in the course to teach first-year students some aspects of ethics, patient communication, and giving bad news. Before working through this case, the students have had an introductory lecture covering the basics of giving bad news and should be ready to apply those principles to “real life” medical situations. Source material for this case can be found at the following two websites:
After completing this case, students will be able to:
Most medical students do not relish the thought of giving bad news to patients. In fact, experienced physicians are often concerned about the specifics of giving bad news. This case is designed to help students explore the issues associated with the delivery of bad news and is centered on the following issues:
While this question may seem obvious, it is important to remember that what the physician feels is “bad news” may not match what the patient feels is “bad news” and vice versa. I am reminded of a situation in which a patient had an episode of facial tingling that lasted several hours. The patient saw her physician, who ordered diagnostic tests. When the tests came back saying the patient had a transient ischemic attack (“mini-stroke”), the physician was concerned about delivering this bad news to the patient. However, when told, the patient responded, “Oh, what a relief…I thought it was MS.”
Physicians often tell patients that they have chronic diseases (hypertension, diabetes, high cholesterol, etc.). Those illnesses are so commonplace in the medical field that the physician may forget that these represent “bad news” to some patients. As an example, the diagnosis of diabetes may be devastating to a patient who witnessed a relative with amputations or on dialysis due to its complications. It is important for the physician in training to remember the patient’s perspective when determining what constitutes “bad news.”
Contrary to what many physicians have thought in the past, recent studies have proven that most patients do want to know the truth about their health conditions. In fact, 90% of patients surveyed would want to know about a diagnosis of Alzheimer’s disease or cancer. In the 1960s, only 10% of physicians believed it appropriate to tell a patient about a fatal cancer diagnosis. However, 20 years later, 97% of physicians felt the disclosure would be appropriate.
Today, most physicians believe that telling patients the truth fosters trust and demonstrates respect. The patient should be told all relevant information regarding the illness, expected outcomes, treatment options, risks and benefits of treatment, and other needed information based on the patient’s specific values and needs.
Sometimes, families will ask that the physician withhold the diagnosis from the patient. Most often, the justification for this is commendable—the family wants to spare the patient a painful or difficult experience. However, those fears are usually unfounded. In rare situations, the family may reveal that telling the truth will cause the patient extreme distress, or may cause predictable harm to the patient. In those situations it may be appropriate to withhold the information. Most often, telling the truth in a thoughtful and empathetic manner will be more appropriate than withholding.
There are two instances where withholding the truth may be justified. In the case where disclosure is likely to cause real and predictable harm, it may be appropriate not to disclose. In addition, if the competent patient asks not to be told the results or the truth, it may be appropriate to respect this desire. It is important to treat this instance like an informed consent. The patient should be notified regarding the consequences of this action, and if those consequences are accepted, the patient may not be told.
Sometimes there isn’t a right answer to this question. At times, the primary caregiver may be the best person to deliver bad news. However, often, it’s the specialist or another caregiver that finds him/herself in a position to give the news to the patient. In any case, the care team should do its best to work together and deliver care as effectively as possible.
While there are many recognized approaches to giving bad news, one effective method has been described by Buckman and broken into six steps that can be applied to almost any situation. The protocol is attached, and can also be found at the website at http://eduserv.hscer.washington.edu/bioethics/topics/badnws.html.
This case is intended for a group of 12 to 20 students. Begin the class by letting the students know that the case is designed to focus on different aspects of delivering bad news to a patient. Inform them that in their future clinical practices they will be wrestling with questions concerning whether or not patients want to know the truth about their condition, how much the patients should be told, at what time they should be told, and who should be the one to tell the patient the news. Then, ask a student to read the case aloud to the class. Alternatively, the facilitator can use the case as an opportunity for role-play. Four students can participate, with one student playing the role of the patient, John Davidson, one student playing the role of Dr. Miller, one student playing the role of Dr. Quaid, and one student acting as narrator.
After the case is read or acted out, ask the class to assume that the pathology report came back as adenocarcinoma of the colon, and there are likely metastatic lesions on the liver. Next, divide the class into two separate groups. Identify group #1 as the “when and who” group and group #2 as the “how and what” group. Ask the two groups to meet in separate areas of the classroom. Use the blackboard to describe the tasks to be accomplished by each group.
On the blackboard, write down the following questions to be answered by group #1:
Obviously, each of these questions has two potential answers. In their group discussion, ask students to explore the advantages and disadvantages associated with each option, to select the option they feel is best, and to list reasons that support each of their answers. Request that the group arrives at a consensus, and ask them to choose a spokesperson to present their answers to the rest of the class.
On the blackboard, write down the following questions to be answered by group #2:
Group #2’s questions are obviously more open-ended as compared to group #1. Ask students to fully answer each question, and choose a spokesperson who will present their answers to you and group #1.
After each presentation by the spokesperson, provide time for the other group and yourself to ask questions and make comments regarding the presentation. Allow 15 minutes for the discussion phase and 20 minutes for the presentation and question/answer component.
Issues that may surface in group discussion and presentations:
The Buckman bad news protocol lists language and specific steps that are effective in breaking bad news to patients. Print out the document from the website at http://eduserv.hscer.washington.edu/bioethics/topics/badnws.html (also available as an attachment to this case) and distribute this document to the class. Tell students this material was developed by a practicing oncologist, has been widely disseminated in medical school curricula, and has been found to be effective in research studies on this topic. Facilitate a discussion on the similarities and differences between their answers to questions posed to each group (particularly group #2) and the Buckman protocol.
Next, tell students you would like to conduct a brief role-play. Go with group #1’s presentation on when this discussion will occur, who should communicate the diagnosis to the patient (primary care physician or specialist), and who should be present for the discussion (patient alone or patient and spouse together). Ask for two or three volunteers (depending on whether or not group #1 suggested the spouse be present)—one to play the physician, and one to two to play the patient/spouse.
At the end of the role-play, thank the volunteers and ask them to comment on what this exercise felt like to them. Ask the class to constructively critique the performance of the physician, with an emphasis on what he/she did well.
In closing, the facilitator can share clinical experiences, both good and bad, in which he/she had experience sharing bad news with a patient. The facilitator should stress that no approach works perfectly every time, and that preparation and sensitivity are valued qualities in every situation.
Acknowledgements: This case was developed with support from the National Science Foundation under CCLI Award #0341279. Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the National Science Foundation.
Date Posted: 02/02/06 nas
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Originally published at http://www.sciencecases.org/bad_news/bad_news_notes.asp
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