Communicating Bad News to Clients
By Chelsea Greenberg, DVM, MS, Diplomate ACVIM (oncology)
Excellent communication between clients and the veterinary cancer care team is vital for the best patient outcomes regardless of diagnosis. Historically, veterinary curricula are heavily focused on medical sciences with little time spent on the development of communication skills. This leaves many veterinarians poorly prepared for difficult and/or emotionally charged communication that can occur when delivering bad news like a cancer diagnosis, unexpected death under general anesthesia, or an unsuccessful resuscitation of a critically ill patient.
The bearer of bad news often experiences strong emotions such as anxiety, feeling responsible for the bad news, or fear of a negative evaluation.1 These normal emotional responses can make veterinarians reluctant to deliver bad news. With proper training, it is possible to develop a skill set that increases your confidence during these situations.
When giving bad news, there are 3 main approaches: 2,3
Patient (client)-centered approach: The veterinarian conveys information according to the client’s needs and encourages the client to talk about feelings and concerns. The veterinarian checks for comprehension of the information and demonstrates empathy. 4
Disease-centered approach – The veterinarian presents blunt and insensitive information without involving the client’s feelings or goals.
Emotion-centered approach – The veterinarian focuses on the sadness of the message with excess empathy and sympathy. With this approach, the veterinarian avoids raising false hopes.
The patient-centered approach is the preferred communication method for delivering bad news in human medicine. Patients that received bad news with the patient-centered approach perceived their physician as more emotional, less dominant, and more appropriate when delivering information. They also viewed their physician as more available and more hopeful compared to perceptions with other communication styles.3
If veterinarians lack proper communication training, delivering bad news may lead to negative outcomes for their patients, their clients, and themselves. In an effort to improve clinician communication, several training methods for the patient-centered approach have been evaluated in human medicine 1-5, and these may be useful for veterinarians. A common strategy among these training methods is to break down the communication process into discrete steps.
Outlined below is a stepwise approach to client-centered communication that can be used when you need to deliver bad news:
Step 1 – Prepare for the discussion
Review your plan for communicating bad news to the client and how you will respond to the client’s questions and emotions. Although bad news will be sad for the client, it is important to remember that they need to have this information to be able to act in their pet’s best interest.
Also, ensure the environment is conducive to a sensitive discussion:
Deliver the message in person. Do not deliver hard messages with a text or email as they are flat forms of communication.
Arrange for privacy
Get down to the client’s eye level, do not stand over them
o Stoop down
o Sit next to them
o Sit on the floor
Soft, kind interactions with their pet
Reaching out a hand to the pet
Petting or holding the pet during the discussion
Gentle body language
Remove obstacles between you and the client (do not “hide” behind the exam table or a clipboard)
Do not cross arms
Make gentle eye contact
Have open hands, do not clench fists or point with one finger
Manage possible interruptions
Turn off pager/phone
Notify the staff about your availability
If interruptions are expected, notify the client beforehand
Step 2 – Assess the client’s perception
This step helps you learn what the client already knows about the disease as well as their depth of understanding. Exploring the client’s perception will help you tailor the news to match their current level of understanding. This is an important step because it helps you determine if the client is in a state of denial or has unrealistic expectations for treatment.
Ask open-ended questions about how the client perceives the situation:
Examples:
“What have you been told about your pet’s condition so far?”
“Do you understand why we did the chest x-rays today?”
Correct any misinformation
Tailor information to the client’s understanding
Step 3 – Discuss how your client would like the information
Discuss with the client how they would prefer to receive information. Clues about this can be ascertained during the diagnostic process when you learn how they would like test results conveyed.
Examples:
“How would you like me to give the information about test results?”
“Would you like for me to give details of results, or provide a summary and spend more time on treatment options?”
Step 4 – Present the information
Warn the client that bad news is coming, as this can help lessen the initial shock and help facilitate their processing of the information.
Examples:
“I’m sorry to have to tell you…….”
“Unfortunately, I have some bad news”
Provide information at the comprehension and reading level of the client (average is 6th grade level) to improve understanding
Avoid medical words and jargon
“Spread” instead of “metastasize”
“Tissue sample” instead of “histopathology” or “biopsy”
Avoid being too blunt (yet be direct in communication)
Give the information in small chunks and check periodically for client understanding
Have them repeat information back to you, especially if they don’t appear to be retaining the information. This also helps them own the conversation.
Watch for non-verbal clues if they seem to have difficulty understanding, or accepting, the information
Looking down when speaking
Arms crossed and/or leaning back
Avoid doomsday phrases
“There is nothing more we can do” – the client may want accomplishable goals such as pain management, etc.
Step 5 – Address the client’s emotions with empathetic responses
This can be the most difficult step in the communication process. The client’s emotional reactions to the information can vary from silence, to disbelief, to crying, to anger, and may include more than one and change between them during the course of the conversation. You can provide support by making an empathetic response.
One process for developing empathetic responses:
Observe the client for emotions; look for sadness, shock, etc.
Identify the emotion that the client is experiencing. If your client is silent or looking away, ask open-ended questions to help gauge how they are feeling or what they are thinking.
Identify the reason for the emotion which is usually the result of the bad news. However, if you’re not sure, ask open-ended questions.
After the client has expressed feelings, let the client know that you understand the reason for the emotion
Example:
Clinician: “Unfortunately, I have some bad news. Fluffy has been diagnosed with hemangiosarcoma, a type of aggressive cancer. When we took chest x-rays today, we saw spots on her lungs that are concerning for cancer spread.”
Client: “Oh no! (crying) My Fluffy is too sweet, this can’t be happening to her!”
Clinician: (Sits closer to client) “It must be upsetting to hear this; I wish I had better news”
Additional information cannot be comprehended until the emotion has cleared. Initially, the clinician can continue to make empathetic statements, including a show of support by mentioning their own sadness (“I also wish the news was better”). Including a show of support can help the client feel their emotions are validated. However, if the client continues to struggle with their emotions, it may be best to schedule time another day to continue discussion.
Step 6 – Strategize and Summarize
Having a treatment plan helps the client feel more certain and less anxious. Before communicating the treatment plan, you should ask the client if they are ready to discuss it. Waiting until the client is ready shows compassion, honors their wishes, and helps improve understanding. Be sure to check periodically while delivering the treatment plan to make sure that the client is understanding the new information and correct any miscommunications. Providing written materials can be helpful to reiterate discussion points and provide additional resources. You should also arrange any needed follow-up. After you’ve finished the discussion, you need to take time to process your own feelings.
When the outcome is likely unfavorable, veterinarians may feel uncomfortable and therefore reluctant to start discussing prognosis and treatment options. This discomfort usually arises from the fear of being blamed, fear of expressing emotion, fear of not knowing all the answers, fear of the unknown and the untaught, and feeling unprepared to manage the client’s emotional reactions.1,6 While communicating bad news, the veterinarian may inadvertently give the perception of taking responsibility for the disease process which makes them become a target for the client’s anger and frustration. To be seen as an ally and supporter of the patient and client during this challenging time, certain communication errors must be avoided.1
1. Painting an overly optimistic picture (shielding):
The veterinarian means well and wants the news to be good. Wishing for a successful outcome does not make it happen. All relevant information must be presented to the client, upsetting or not, so they can make the best treatment decisions (allowing the best possible outcome) for their pet.
2. Taking credit for remission:
Talking about potential recurrence and/or metastasis is unpleasant, and it can be tempting to not discuss it. Many clients would rather hear the words “cure”, or “we got it in time”, or “we got it all”. They will often attempt to encourage clinicians to engage in this terminology and it is challenging not to agree with them in the moment. Problems arise when a cure is promised, because any recurrence or disease progression will be seen by the client as a personal failure of the veterinarian.
3. Controlling information:
Veterinarians are trained to treat disease, and it can be difficult for them when this is not possible. This frustration may lead the veterinarian to try to gain control over an unfortunate situation which may be manifest as controlling the flow of relevant information to the client. This may cause a client to believe that the veterinarian is completely in control of the situation; if the outcome is not favorable, the client believes the veterinarian is personally to blame.6
Delivering bad news is one of the most difficult tasks that veterinarians face in practice. With a little planning and training, delivering bad news can become less challenging. Effective communication helps decrease stress and improve relationships between you and your clients and ultimately leads to better care for your patients.
References:
1. Baile WF, Buckman R, Lenzi R, et al. SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist 2000;5:302-311.
2. Brewin TB. Three ways of giving bad news. Lancet 1991;337:1207.
3. Schmid Mast M, Kindlimann A, Langewitz W. Recipients’ perspective on breaking bad news: How you put it really makes a difference. Patient Educ Couns 2005;58:244-251.
4. Fine RL. Keeping the Patient at the Center of Patient- and Family-Centered Care. J Pain Symptom Manage 2010;40:621-625.
5. Rabow M.W. MSJ. Beyond breaking bad news: how to help patients who suffer. West J Med 1999;171:260-263.
6. Buckman R. Breaking bad news: why is it still so difficult? BMJ 1984;288:1597-1599.