HealthFebruary 12, 2020

Tips for difficult conversations with patients

By: Heidi Moawad, MD

No matter how many tips for difficult conversations you hear, delivering bad news is a challenge. The patient sitting in front of you may not have the worst prognosis you’ve seen—but you still know that it’s the worst news they’ve ever had to swallow.

Certain topics are notoriously tough. When you know your patient is going to have to make a difficult decision or give up something they always wanted, you realize that your upcoming chat will change them forever. For example, telling a patient that they carry a genetic illness that could limit the lives of their future children can crush them. Or, after you cautioned your patient’s family that a life-saving procedure might not work, relaying the news that it didn’t work still delivers an undeniable shock.

Giving your patients options isn’t necessarily easier. Telling a patient that you are ready to discuss the pros and cons of an intense medical treatment that will only prolong—rather than save—their life ends up spelling out the harsh reality of how many months they have left to live.

As tough as these discussions can be, knowing how to approach them can help make them sting a little less. Here are some tips for difficult conversations.

To learn more about difficult conversations with patients, visit AudioDigest.

Preparing for the conversation

There’s no way to avoid difficult conversations when you’re a physician. But they can be easier on your patients if you build an environment of comfort, even before you know with certainty whether you will have any bad news to discuss.

According to an article in Academic Medicine, challenging discussions are more effective when doctors build trust and explore the patient’s perspective. These aspects of the relationship have to take place in advance. When you’re ordering a diagnostic test for a condition like diabetes, it helps to know whether your patient has known others who are living with the condition and whether your patient can visualize a happy life if diagnosed. This insight can help you anticipate how your patient is likely to react and can help you prepare for the right type of support and direction once the test results start to trickle in.

Gauging how it’s going

There are a number of steps you can take during a tough exchange to help your patients process the discussion. An article in Qualitative Health Research assessed the effects of physician communication during the decision-making phase of miscarriage. Women rated their experiences as better when physicians were empathetic, avoided medical jargon and emotionally charged language, allowed them time for processing the information and checked for understanding.

There’s no question that some patients are going to be in denial when they hear bad news. I vividly recall a patient who forgot our conversation at least five times when I was given the disheartening task of telling her that her young son needed brain surgery to remove a traumatic cerebral hematoma—and that he might not fully recover from the severe head trauma. I started the discussion from scratch every time and realized she needed time to process the overwhelming news. Understandably, it took time and multiple rounds of communication for her to process the severity of what was going on. Ultimately, she made all the best decisions and took meticulous care of her son, thoroughly learning the complexities of managing a ventricular shunt.

Following up afterward

After you’ve had your talk, the story is just starting as far as your patient is concerned. For them, the conversation—a new diagnosis, a bad prognosis or a life-altering handicap—may have changed everything. They have to begin living life differently from yesterday.

If your difficult conversation was reassuring for your patient, they may remain your patient for quite a while longer. Sometimes though, your patient may decide to leave your care. It could be due to some aspect of the difficult conversation that disappointed them. An article in Patient Preference and Adherence explains that patients may decide to switch to another doctor based on the delivery of bad news. No matter how well you communicated or how hard you tried to ease the pain, some patients may associate you and your clinic with the day their life changed for the worse—and some may leave your care simply to avoid those bad memories.

Continue to communicate with your patients consistently and empathetically to provide them the best support during the difficult time.

Heidi Moawad, MD

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