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November 23, 2012 | Posted By Jane Jankowski, LMSW, MS

Giving bad news is a difficult thing to do. Receiving bad news is hard, too, but is perhaps a close second to hearing a complicated, vague version of the same set of facts. In healthcare, the failure to disclose pertinent facts in clear, uncomplicated language and verify the information is understood is harmful to the recipient of this information, but also to the provider, who must often untangle the resulting misunderstandings later on.  Families and patients who find they are asking "Why didn’t someone tell me?" may be on the receiving end of an attempt to give bad news.

I tend to think of these vague communication moments as 'dodges.' Rather than stating "I believe your Aunt Lila’s condition will not improve and we need to talk about what kind of care she would want" is instead a listing of diagnoses, medications, lab values, and a review of body systems, surgical options, and statistical probabilities. This type of encounter shifts the focus from the overall prognosis to the details, which though factual, obscure the big picture of a patient who is not expected to recover. Avoiding a frank disclosure of the fact that a patient is doing poorly doesn’t help the patient, and does not help anyone make informed decisions. But it serves a purpose in the moment. Sidestepping the straightforward presentation of bad news may avert or postpone the experience of delivering upsetting news and witnessing the emotional suffering of others who hear it. I get it. It is stressful and distressing to be the source of often devastating news. Yet, we must keep in mind that the news itself is the source of the upset, and the bearer of the news need not feel morally culpably for the facts. The old adage applies, 'it’s not what you say, it is how you say it.' We owe it to medical providers to give them adequate practice and training in delivering bad news as well as opportunities to observe experienced practitioners talk with patients and families when critical conversations are held.

Does a failed attempt to convey bad news constitute an ethical violation? Not necessarily.  The principle of transparency requires providers be open and clear about medical facts and options. The intent of even the most epic dodges is often to protect the patient and even family from being unduly upset, not cover up the facts. However, intentionally deceiving others about medical facts and prognosis is ethically problematic. Where I believe the majority of misunderstandings begin is in a gray zone of incomplete information, unclear language, and acting on unconfirmed impressions. Though not a clear intent to deceive, and perhaps driven by the desire to insulate everyone from painful feelings, the result is precisely these consequences – the perception of deception, negative feelings, and mistrust. The reality is that miscommunications will happen, but we owe it to our patients and their loved ones to do our best to maintain transparency and when a misstep occurs, openly address the problem with respect and humility.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

1 comments | Topics: Communication, Doctor-Patient Relationships, Patient Care

Comments

sheila otto

sheila otto wrote on 11/23/12 10:53 AM

Well said Jane. Delivering bad news is uncomfortable, and may be met with anger, disbelief, denial, etc. all of which are difficult for the physician. Too often, I have seen docs focus on lab values or data, rather than the big picture. Facts are the groundwork for medicine as a science, but the art is in helping interpret that data. This may further be driven by the desire to give some "hope" and the knowledge that we do not always prognosticate without error, both marginally legitimate claims. However, in my experience, bad news can be delivered in a kind, compassionate and transparent manner which ultimately serves the patient, family, and yes, the physician, well.

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