Breaking the News

From OncoLog, October 2005, Vol. 50, No. 10

Breaking the News

by Rachel Williams

How would you want to get the news of a life-threatening disease? From a voice on the other end of the telephone line or from someone who talks to you in person? In a crowded waiting area or in a private, comfortable office or room? From someone that you barely know or from the health care provider that you have entrusted with your diagnosis and treatment?

These are questions that Estela Beale, M.D., an associate professor in the Department of Psychiatry at M. D. Anderson, suggests physicians ask themselves to remain aware of the psychological and emotional impact with which a diagnosis of cancer slams into a patient’s reality. Paying attention to certain aspects of the doctor-patient relationship can reduce the effect of bad news while paving the way for a strong working relationship. When physicians are mindful of their own reactions to the patient and the patient’s medical condition, they are better prepared to deliver the news.

“The traumatic effect of a diagnosis of cancer is apparent in most patients,” she said. “Even for those who already suspect the possibility of cancer, having that fear confirmed is still traumatic. Different people may respond to the shock in different ways, and physicians should be aware of signs that suggest a patient is having difficulty.”

Typical responses

According to Dr. Beale, the most common reaction to a diagnosis of cancer is a state of shock that results in feeling stunned and dazed. The patient and the family tend to feel disbelief about what they hear. People often feel numb for several days. Cognition is affected, making it difficult for the patient to concentrate, understand what is being said, ask questions, or absorb explanations and treatment information being offered by the doctor. Frequently, such patients have trouble sleeping, eating, or handling their normal routines because their minds keep reliving the diagnosis or because they are consumed with fear about what will happen. For the patient, hearing the diagnosis can be like hearing a death sentence. Physicians should be aware that during this stage, a patient may fail to follow through on instructions or participate in prescribed treatment without additional help and encouragement.

Another reaction, seen more frequently in the elderly, is an apparently calm acceptance. These patients may show no particular shock or surprise and instead seem stoically resigned to the diagnosis. However, underneath a calm exterior there may be a great deal of grief, guilt, or despair.

“Very often the patient is thinking that he caused the cancer as a result of something he did or did not do,” stated Dr. Beale. She said that these patients tend to become lethargic, sleep excessively, and sometimes fail to follow treatment plans.

A third reaction, which is more typical in adolescents and young adults, is denial. “These patients develop a need to avoid the reality of cancer altogether and refuse to talk about it or hear the word ‘cancer’ mentioned in their presence. Their way of dealing with the diagnosis is to pretend the disease does not exist,” Dr. Beale stated. “They feel that the only way to remain whole is to stay in control of the information by not allowing discussion or even thoughts about the illness. If it’s out of their minds, they can pretend it’s not real, and like a nightmare, it will all go away.” One problem associated with the denial reaction is a reluctance to go to treatments or follow procedures or even to talk about the subject with anyone. These patients typically have compliance problems.

“It is also normal for people to go through a combination of all three phases to a greater or lesser degree,” said Dr. Beale. “Fortunately, most patients, sooner or later, are able to move past the shock of diagnosis and, with time, come to terms with their condition and move in the direction of getting their lives back to normal as much as possible.”

Softening the blow

According to Dr. Beale, there are a few simple things that physicians can do to make a difference in a patient’s ability to handle the initial effect of diagnosis and move past that stage into acceptance and readiness to fight the disease.

Remember your importance to the patient. “First, consider the importance that you, as a health care provider, have in the mind of the patient. To be mindful of that means remembering that the task is not just to convey information, but to do it in a way that takes into account the patient as a whole person.”

Give the diagnosis in person. “Never give a cancer diagnosis over the phone. It is very impersonal and detracts from the doctor-patient relationship. The doctor-patient relationship is very important since it provides the context in which trust, confidence, and hope develop. Even under the worst medical conditions, a good connection with you gives a patient a sense of security in facing the challenges of the illness and treatment.”

Provide a quiet, relaxing environment. “The room or area in which the diagnosis is given should be as private as possible and have comfortable seating. Certainly, never give the diagnosis out in a busy hallway or a crowded waiting room.”

Take extra time for the diagnostic visit. “The physician should plan to spend a little extra time with a patient when breaking bad news to allow them to react, ask questions, and absorb the information.” Information should preferably be given in small amounts to give time for reacting, questioning, and assimilating.

Let some time lapse between the diagnosis and discussion of treatment options. “Doctors need to remember that at the time of diagnosis, very often patients only remember about half of what they have been told because they are so frightened and overwhelmed. Once they’ve heard the word ‘cancer,’ everything else you say may be a blur to them, even if they appear to be taking it all in. It may be helpful to schedule a separate session to discuss treatment options and review key information. If that is not possible, provide patients with written information or ask them in advance to bring a supportive friend or relative with them to take notes and serve as a second pair of ears. Some practitioners tape or write down information that was discussed during the session so that patients can go home and review what they have learned.”

No one can protect a patient from the shock of being told, “It’s cancer.” But, as Dr. Beale points out, it really does help the patient cope with and absorb the news more easily if the diagnosis is given under conditions that allow the patient to react as needed. A strong relationship inspires trust and allows the patient freedom to express thoughts and anxieties about the illness or the treatment.

For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789.

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