No one wants to be the bearer of bad news, especially to a patient that you have worked so hard to guide through treatment. Unfortunately, having these hard discussions is a part of working in oncology. In part 1 of this 3-part series, I discussed how the oncology care team can prepare for these conversations by preparing themselves and the patient at the beginning of treatment. In this installment, I will discuss the primary reasons healthcare providers don’t want to give a patient bad news, and how we can make our patients more comfortable.
Nurse navigators, patient navigators and other members of the oncology care team may feel uncomfortable having hard conversations due to:
- Fear of upsetting the patient and what reaction they may have
- Feeling as if they are taking away hope from the patient
- Fear of their own emotional reaction, especially after a long treatment road together, the provider may become emotional or speechless
- Some have said that this kind of news makes them feel like a failure to themselves or to their patient
- Being afraid of any emotionally-charged questions the patient may ask.
A plan should always be set in place on how a patient prefers to handle difficult conversations. For example, if you anticipate bad news from the scan results, you can recommend having the conversation in person. Have the patient come in, or even delay the discussion until their next appointment, when options for treatment/care will also be discussed. If good news is anticipated, then this can usually be managed by phone.
In either case, the patient needs to be in an environment of privacy. There should be a time established when making the call to ensure the patient isn’t at work or in an uncomfortable situation and if getting bad news by phone, the patient should have a loved one with them. If possible, utilize a video call over phone calls because they give the ability to see one another face-to-face.
Use the following tips when delivering bad news:
- Find a quiet consultation room
- Do not appear rushed
- Provide pauses during the dialogue to enable processing of information, reaction to information, and opportunity to ask questions during the conversation
- Maintain eye contact
- Give patients and families the opportunity to weigh benefits and negative impact of treatment based on information we know–treatment response rates, toxicity, even cost
- Avoid using medical jargon like “spiculated, lesion, shadow, uptake, lymphovascular invasion,” as these are terms we are very familiar with, but the patient is not.
It is always wise for all members of the care team to be prepared for such conversations. Here is a good example of a conversation delivering hard news:
“As I mentioned yesterday during the biopsy, the area I pointed out to you on the mammogram/ultrasound looked suspicious. It did come back confirming it is cancer. The breast cancer survivor volunteer who was with you yesterday will be calling you at home tonight if that is okay with you. You will also get a call from our breast cancer nurse navigator.”
You can then take the time to explain what the navigator will go over on the call and state any hopeful features–small tumor, slow growing, favorable prognostic factors, and what that means. Be VERY clear about the difference between stage and grade for those who have stage 0-III cancers.
In advance of communicating with the patient, you can schedule them with the appropriate doctor to show a plan is underway and say something like:
“The nurse navigator has already scheduled you to see the doctor the day after tomorrow. This doctor is excellent and specializes in this field…You will be in good hands. There will be an entire team to take care of you and support you through your journey.”
We are privileged to be in the cancer patient’s life during this extremely vulnerable time. Step in when you need to as a way to make sure the patient understands their clinical situation and their goals of care. Make sure the patient’s family is not trying to control the situation and force them to continue treatment when they don’t want to anymore. Prepare your patient by involving palliative care early on. Even after a patient dies, you can look back and know that you did your job well as a navigator for this patient and their family.
Take the time to look at these short videos to use as teaching tools and resources: