The doctor holds the test result and stares blankly at the patient. The science is clear, but what's unclear is how to tell the patient that life is coming to an end. How do you translate scientific jargon and statistical data into a direct and compassionate message? “There is no cure for your illness.”
A recent study by a group of communication researchers revealed some of the most common barriers to effective “bad news” conversations between patients and clinicians. The result is COMFORT, a new approach to training clinicians how to effectively break bad news.
COMFORT is not a checklist, but rather a set of interactive guidelines to help adapt bad news messages to the needs of patients and families. By following checklists, clinicians end up making mistakes, such as handing the patient a Kleenex, even when the patient isn't even crying. In reality, every patient is unique and so is every bad news interaction. COMFORT allows clinicians to adapt to the actual needs of the patient.
Delivering news about a serious illness is always difficult, but most clinicians still lack formal training on how to effectively communicate bad news. In a New York Times interview on the lack of attention to breaking bad news in medical education, prominent oncologist and researcher Dr. Anthony Back said, "The general feeling has been that these are not teachable skills - that either you have it or you don't. "
COMFORT was developed based on evidence from communication research in which medical students were trained using an existing protocol for breaking bad news, and were videotaped as they delivered bad news to patients and family members. The students then discussed the experience of breaking bad news with medical school educators and communication experts. From those discussions, seven common themes emerged about barriers to effective bad news interactions, and seven corresponding guidelines were created to help overcome the most common barriers.
The result was COMFORT, an acronym that stands for Communication, Orientation, Mindfulness, Family, Ongoing, Reiterative, and Team.
Communication- Clinicians should use clear and familiar language when breaking bad news. The emotional discomfort associated with delivering bad news can lead clinicians to use vague or unfamiliar language that masks the true meaning of a negative diagnosis. Vague terms such as “Your condition seems to be terminal” are used, instead of saying “there is no cure for your illness.” Delivering bad news requires verbally and nonverbally direct communication that makes sense to the patient. Otherwise, patients can leave the doctor's office without fully understanding the reality of their healthcare situation.
Orientation- A patient receiving bad news can have unrealistic expectations about a cure for their disease. Realistic expectations for treatment should be clearly stated in plain language so there is no confusion about treatment goals. Orienting patients to the reality of their condition helps prevent unwanted treatments and unrealistic expectations about recovery.
To ease the discomfort of delivering bad news, clinicians may use statements about expectations to reveal the biomedical aspects of a negative diagnosis (i.e. “I expect you will experience symptoms including …”), but mix those statements with expressions of hope such as, “I am hoping to ease your pain by giving you medication.” Patients who are clearly oriented to the reality of their health status have the opportunity to make decisions accordingly.
Mindfulness- Clinicians should pay attention to what is happening in each moment, and respond to the changing needs of the patient during a bad news discussion. Mindfulness means avoiding distractions, both verbally and nonverbally, when delivering bad news. Actively listening and maintaining eye contact can show the patient you are truly present. The patient should be the center of attention; bad news interactions should never occur in a busy hallway. Clinicians sometimes use terminology such as, “the cancer has metastasized,” out of habit. Mindfulness helps clinicians think before they speak, and rephrase the statement to say, “The cancer has spread to other parts of the body.” Bad news interactions are no time to put your mind on autopilot by using a script or rehearsed checklist.
Family- Families should be included in conversations when doctors break bad news to patients, since families provide support to the patient. It is common for a family member to be present when a serious diagnosis is delivered, so clinicians need to anticipate their presence. This can be achieved by acknowledging the family member as a good source of support for the patient, and by integrating the family members into the conversation after breaking the bad news. Although the patient's needs are the most important consideration when breaking bad news, clinicians can build trust and understanding with family members by actively engaging them in the dialogue as it occurs. Practicing in advance how to talk to the patient without a family member in the discussion can be unrealistic if a family member will be present. Family members can be strong allies to comfort a patient receiving bad news.
Ongoing- Stressing there will be ongoing care can avoid a feeling of abandonment by patients after hearing bad news. A clear finding from this research is that the results of bad news require ongoing dialogue and medical attention. Breaking bad news is not a one-time event. By continually communicating with patients, clinicians can provide more clarification about the diagnosis, especially if the recovery will not be quick. Each visit, the clinician should give a very brief summary of the recent past, present and future treatment plans and expected goals for treatment options. This can be achieved in a few short sentences, but by offering a treatment summary, the patient remains aware that the process is ongoing and members of the clinical team have an overall treatment plan.
Reiterative- Reiterative communication refers to the need to restate bad news messages over and over to avoid false hopes for a cure as treatment progresses. The meaning behind the reiterative messages will be the same, but the way it is stated may be changed. For example, instead of discussing only the most recent test results' new developments, a clinician might say, “Now you remember last time we discussed…” to quickly restate the facts about the diagnosis and treatment plan. Clinicians can answer questions, provide feedback, and reinforce the bad news diagnosis to help patients come to terms with the situation.
Team- Patients receive care from a team of medical professionals, including physicians, nurses, chaplains, psychologists, and social workers. Communicating as a team to the patient, and with each other, helps avoid mistakes, and helps reassure patients and their families that they will be receiving proper care. Electronic medical records can be useful to share information among team members about a patient, but since patients cannot see these records, clinicians need to constantly keep the patient updated through face-to-face dialogue. Every health care team member should reiterate the facts of the diagnosis to make sure the patient continues to have realistic expectations about their condition.
Using COMFORT to share bad news with patients and their families can decrease opportunities for confusion or miscommunication, while at the same time increasing chances for understanding and trust in communication.