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Bearing Bad Tidings
Guidelines for preparing and delivering bad news to your patient.
BY LESLIE GOLDBERG, Associate Editor

Get a plan

The following is a course of action that should help to reduce your anxiety and prepare you for addressing your patient:

► First, it's imperative that you are prepared to deliver the news, says Joel Schwartz, M.D., chair of the department of psychiatry at Abington Memorial Hospital in Pennsylvania. Allot enough time in your schedule for delivering the news and responding to your patient's concerns.

Dr. Schwartz recommends, "Whenever possible, make this the last appointment of the day so that you will be able to give your patient your undivided attention and have fewer chances of interruption."

► Next, have the information you need readily available. Make sure that you are able to present physical evidence to your patient and can verify your diagnosis.

► Deliver the information as clearly and concisely as possible. Remove as much medical jargon as possible. Mr. Stoner recommends that the O.D. create a script. "Type out and rehearse what you are going to say. It is important that you feel prepared when delivering your news."

► Body language is extremely important. Using the proper body language is almost as important as the delivery of your message. Dr. Steve Lancaster of the Atlantic Eye Institute in Jacksonville, Fla., recommends that you "keep eye contact, sit at the same level as the patient, keep your back to no one and keep focus mostly on the patient while involving other support members." (Both Dr. Lancaster and Mr. Stoner have lectured on the subject of presenting bad news at Vistakon's Vision Care Institute.)

► Recognize the importance of observing a patient's reaction to the news you have delivered. Provide your information in small chunks. If a patient appears to be confused, ask them to repeat what you have said in their own words and then clarify any misunderstanding, says Dr. Lancaster.

► Once you have delivered the news, it is important that you encourage the patient to ask questions. Find out what the patient already knows about the condition and how much he wants to know.

► Allow your patient to vent. Whether it's anger, sadness or relief, it is very important that your patient be allowed to react to the news.

► Be sure to validate the feelings of the patient. "Never say 'I know how you're feeling' because you don't," Dr. Schwartz advises. "Instead say, 'I can only imagine how difficult this is for you.' " This shows the patient that while you can't walk in his shoes, you are sympathetic to his condition.

► Lastly, have a plan on how to proceed once you have delivered the news.

Guiding them through

"In order to ensure the smooth flow of patient care, it's important to orchestrate the entire process. Explain the current situation to your patient, ask for questions and then direct your patient to a specialist, if necessary. Send a letter to the primary care physician so that he has a full picture of the care his patient is receiving, and explain the possible need for further diagnostic testing," Dr. Lancaster says.

His practice also provides its personal cell phone numbers to patients in crisis so that the patients know they have access to a doctor 24/7. Mr. Stoner reiterates, "Patients to do not come back to you year after year strictly because of your clinical competence. What makes them come back is how you make them feel; your likability."

An O.D. may frequently find it necessary to deliver information that will cause a patient to make changes in his daily life. For example, when delivering the news to an older adult that he may not be able to drive again, you are forever altering his life. The loss of driving privileges can be traumatizing to your patient. You may feel uncomfortable talking about revoking your patient's driving privileges because you don't have any positive solutions to offer.

"Many times the children of elderly patients will accompany their parents to an appointment and beg us to take away their parent's driving privileges. They fear for both their parent's safety and for the other drivers on the road," says Dr. Lancaster. "Not only do we evaluate the patient's ocular status, we need to do a better job of assessing their lifestyle needs and refer them to other services so that they can receive appropriate care." By providing your patient with a physical list of resources, such as alternative travel information or low vision companies, you help them feel less dependent on others and therefore, more in control of their lives.

Changing their lives

On the other side of the age spectrum, you may find it difficult to convince a young child with amblyopia that she needs to wear an eye patch. While this diagnosis may come as a great relief to a parent who's been worried about a child's poor hand-eye coordination or progress in school, it may require a lot of convincing to get a young child to actually wear a patch.

Because the major cause of failure in wearing an eye patch is noncompliance, it's important to help both the patient and the parent get off on the right foot. Help the family to understand why the patch is so important and suggest to the parent that she pass this information on to teachers and friends so that they can be part of a support system. You might also want to talk to the parent about using a reward system or suggest activities that they can do together that will help strengthen the weaker eye.

Be ready with a save

Whatever the diagnosis, it's much easier for your patient to digest bad news if you're able to provide useful information and guidelines for them to follow. Offering relevant support system information, Web site addresses or pamphlet information will help to inform your patients and help them to ask educated questions.

Watch out for these pitfalls

When delivering bad news to your patient, avoid the following mistakes:

► Do not be too blunt when delivering your message. You must realize that what you are about to say may very well change this person's life.

► Choose an appropriate time and place to deliver your news. Inform your patient in advance that your consultation may take some extra time and that he may want to arrive with a family member or companion who can provide support.

Dr. Schwartz warns that under the new HIPAA laws, the only people allowed to hear evidence of the patient's bad news are those that the patient allows.

► Most importantly, do not allow the patient to leave the consultation with a sense of hopelessness.

You're not the bad guy

Giving news that is not positive is difficult. When preparing and delivering bad news to a patient, remember that you are not causing the patient harm; the problem is. Being prepared and well-organized will help you through this difficult task.

In some cases, Dr. Lancaster recommends getting a second opinion from other doctors within the practice and developing a structured plan of action for delivering the news. This will help to alleviate the feelings of guilt associated with delivering bad news. Dr. Lancaster says that during this crucial time, "It is most important to have compassion for the patient and respect their privacy as well as their emotions during this stressful time. Focus on care and concern for the patient's well being."

Don't let it follow you home

Mr. Stoner recommends giving yourself five to 10 minutes at the end of the day to gather "good listeners" from your staff. Ask them, "What worked and what didn't work?" and let them vent. Then it's your turn. Once you have the opportunity to let off steam and receive feedback, you can leave your work at the office and go home.