Perhaps my education and training are different from yours. I do not recall a course, a lecture, a workshop, or even many words on the topic of delivering bad news. For most of us, intuition or personal style is insufficient to provide what the patient needs at this critical and often tragic life stage. Should we attempt to ad lib and hope for the best? Unfortunately, even a beautifully mastered script worthy of an extravagant Hollywood production become wooden and rote when faced with the frequency and enormity of personal tragedy.

This is a paper based totally on the clinical knowledge and observations that I have gained over the past four decades of practice. I have learned that the response to human suffering certainly varies from individual, culture, age, cohort, setting, and the response of the companion of the sufferers.

We all have been exposed to the bromide that one can fall in love at first sight; that the day is won by our first impression; and all that starts well ends well. Although all have some truth to boast, it seems that they are exaggerated in the magnitude of their predictive value. What they do postulate is that the beginning of an interaction has a profound and irreversible influence on the entirety of the relationship and on the process that follows.

Announcing bad news has never been a function of practice with which I had hoped to be intimately aquatinted. Over a very long practice, I have not been successful in avoiding this sad, emotional, and powerful aspect of practice. I can experience few times in life that I feel as totally helpless to be an effective healer for other human beings then when I deliver bad news.

What do the recipients of bad news want?

I believe that delivering bad news is not an isolated adjunct to the treatment process that acts as a prologue to the real beginning of treatment. How bad news is delivered has a major impact on the achievement of positive treatment outcome. How and when bad news is delivered it appears is critical in setting the tone for all that follows. The opportunity before a “good” presentation of bad news is available only once and if lost will never be available again.

I recently took my wonderful well loved middle aged dog, Moses, to his veterinarian's office to have a tumor removed. The surgery went well and I returned home greatly relieved. When we returned to the office for a wound check and a bandage change, the veterinarian was at the reception desk. When we came in, she looked up from the computer and said “we have the lab results back and Moses has cancer. The receptionist can get you the number of an oncologist.” Then without another word, she walked away to the private no admittance inner office of the clinic. I was in shock, couldn't think of the appropriate questions to ask, did not demand further dialogue, and left without the name of the oncologist. This was an example of how bad news should never be delivered. I did in no way blame her for the diagnosis. I did blame her for the harm she did to me, not Moses, with her terrible delivery of bad news.

I know that the news, the information to be presented, is a fixed variable in the bad news equation. If the dissemination of information is all that is involved in giving bad news, power point or a concise e-mail would be the superior and most efficient choice to achieve the bad news giving goal.

I have experienced many times that no matter how well I know the patient, when I walk into the patient's room with bad news, the potential recipient of news will not differentiate between me and the disease or the disease process I am announcing. At that junction I become both the savior and the devil. In the short minutes since I have entered the room, regardless of my intention, kindness, and glow of empathy, I have become the judge, jury, and in some case the hangman. Without exception, everyone in the room is fearful of you. Each person believes that I at any moment will open Pandora's Box and release all the plagues of the world. The relationship that I have enjoyed before I open the door will for all time be inalterably changed. I am now the messenger of harm, suffering, pain, unwanted change, death, comfort, and redemption.

I have observed many others in their turn to give bad news, what I most often see particularly if the clinician has an ongoing relationship with the patient, is the jocular presentation. Humor and exaggerated intimacy can mask the true nature of the process. It can give the impression that what is said, no matter how grave, is not all that serious or the doctor would be taking the news more seriously. Just as harmful is when the patient sees the doctor as taking the material seriously, but not taking the patient as a person seriously. I call this the “now, now little lady, everything is going to be all right” approach while the clinician is using humor and lightness to soften the impact of the news, in actuality, the news is distorted by a light approach because the news “is what it is” and should stand alone. It appears to me that most often the light approach is employed to protect the clinician who is his or herself uncomfortable with what needs to be said. A light presentation does not help to preserve hope or ease patient apprehension or suffering, but rather serves to confuse an essential communication. With this approach, a natural process will have been aborted and a degree of trust in the clinician has been abated.

I have always hated teaching in summer school. In the summer session, in reality, we often attempt to teach lesson one and two at the same time with a less than superb result. Giving the news and the science at the same “lesson” will almost always result in a poor outcome. Anxiety reduces, not increases, the ability of an individual to grasp cognitive information.

My experience has been that of all the factors in giving bad news, emotions are the most problematic. It is sometimes difficult to focus on the patient's emotions for attending to our own strong emotion. Having three adult children and seven grandchildren, I know that I am often overly empathic when the bad news is about a child. If my emotion overshadows the parent's, then any room for their emotion is lost while they either take care of me or move directly into fearing the worse of the worst. Emotions can be loud, intermittent, soft, private, different between different generations, a series of keening, laughter, or silence.

As a Caucasian child growing up in Memphis, I learned at an early age that African-Americans grieve remarkably different from Caucasian southern Baptists and both grieve differently from southern Jews like me. This was all the diversity selection we had in my environment at that time. Now, the world has delivered an array of culture that expands as far as anyone can see. Individuals accept bad news and grieve within the structure of their own culture. If we do not at least know some of the rules of the culture as they grieve then we miss a chance to give bad news effectively and most humanely.

When you prepare to give bad news, keep in mind the Broadway saying: this may be the 2000th performance to you, but it is opening night for the audience. It seems simplistic to say that we should know the patent to which we are giving bad news. In my work, I have attended many funerals. It is always clear when the person giving the eulogy has or has not done the necessary homework. I quite recently attended a funeral during which the Rabbi officiating called the woman of blessed memory by her given name which none of us could recall ever hearing before. He talked about her pride in her three children; she had five and sympathized with her husband on his great loss. I would say her husband died at least 25 years before her death. Even with a ritual providing structure, it was a dismal and insulting occasion.

In giving bad news, the critical ingredient is never news of the illness, prognosis, or treatment, but the bridge of human interaction, which has been constructed. Giving bad news is a full contact activity in much the same manner that football and hockey are full contact sports. All the facilities of the player must be in action at once. A linear strategy will always lead to disaster. Giving bad news is a synthesis of information of what we know and what we know about the person and their family. Just as with a sports team, the teller of bad news must have a commitment to the patient not just for one game, but for the entire season.

I try to never forget the most powerful of all emotional processes, denial. Rational arguments are totally impotent in the face of denial. Only the discovery of the process underlying the denial and resolving the power of that process will reduce the denial. This can take days or months to move from denial to reality. A tug of war between the practitioner and the patient always leaves the patient and the clinician in pain and the denial totally intact.

What I have repeatedly found in my experiences is that “bad news” recipients and their close loved ones approach “bad news” in an idiosyncratic manner which does not appear as prevalent in other stressful situations. When faced with the overwhelming and painful impact of “bad news” the prospect of remaining in the present to deal with whatever the here and now brings is an extremely unpleasant option. It is often related to me that after a very few minutes, the “bad news” individual appears to no longer be listening. I suspect this is because they are no longer in the room of the hospital, emotionally not physically.

I am passionate in my belief that unless history taking is the weaving together of a story with the remembered important events and the people who populate the events, than it is of little value to me. It is in the truest sense, an intimate reach back to stories and recollections before the person could personally remember the event, and extending as far into the future as anyone can see.

As a clinician and incorrigible storyteller, I often use the telling of my stories as the invitation to tell his or her stories; the core material we are hoping to hear. I always start with the “family Bible” asking for verbal and nostalgic recollection of as many generations as the individual can recall. I do not want to know how this cohort of relatives died, but how more important about how they lived their lives. If all goes well with each recollection, the patient moves into the fullness of life and not the narrow life that they are living today in the aftermath of hearing “bad news.”

I have a multitude of feelings that I would like to express when giving “bad news.” Obviously, these must be kept to myself. I have made a commitment to myself that should I cease having these strong emotions when giving bad news, that I would retire or find another job.

I would not do justice to telling of “bad news” if I left out the important role of humor in giving “bad news.” I have already said with some fervor that a jocular presentation when giving “bad news” is a sin. What I want to convey is that clinician initiated humor is inappropriate, misleading, and hurtful to the patient. What I also want to convey is that patient-initiating humor can be a palliative device that allows the patient a greater control of their inner environment. I have been in my share of personal crisis and have met each one with humor and one liners. Why have I done this behavior; because simply, this is who I am. Humor has been a major part of my life and I believe will be a major part of my death. Humor that lightens and strengthens the patient on his or her journey is invaluable. Humor as a defense blocks the process of the “bad news” and leaves the patient in as much pain as is the case when the “bad news” was announced.

For the most part, we are a people of good will. It seems to me that helping professionals, with a few exceptions, exhibit extraordinarily good intentions toward their patients and their loved ones. We are a profession committed to purposeful therapeutic action. It is difficult to make the transition from planned action to passive inaction. When giving “bad news,” it seems paradoxical to honor the patient's need at a time of great turmoil and pain with silence. We are reaching back into a previous century of medical practice when we offer our silent presence by the bedside as an antidote to whatever illness effects the individual or the individual who has just learned “bad news.” When the tragic act of violence was visited on the Amish in 2006, frequently members of the community came to the homes of those grieving and gave their contribution to the healing of the bereaved in a silent presence, a gift of presence.

In the perpetual world of the hospital environment, punctuated by the discordant sounds of many people attempting a broad array of tasks, it is hard to imagine how the prescription of silence can be filled for the “bad news” recipient. Modern medical accounting would react with horror at the prospects of the “bad news” patient receiving such a non-billable service as the “giving of presence.”

In silence, the “bad news” recipient has an opportunity to ramp down the reaction to the “bad news” to the least robust reaction. The “bad news” patient has time in a non-hurried format to assess the situation and make a well thought out plan. Silence for many is a doorway to some peace in which the “bad news” is minimized.

A last note on silence: sitting quietly with no activity and not fidgeting or falling asleep is a task much more difficult than it would seem on first examination. Silence is an integral part of some cultures. Silence is a skill that in some cultures is taught to children as part of their heritage. Most of us lack the training and the skill to be good practitioners of silence.

I believe that we all have suffered a great loss at the hands of the unspoken prohibition against a free and open discussion of any aspect of religion. What a strange paradox, we can freely talk about sexual practices and not religious practices at all. In my interpretation, religious freedom does not dictate a course of action in which the existence of religion is not discussed or acknowledged.

I do not subscribe the World War II saying that postulates that “there are no atheist in a fox hole.” I do believe that no one can live in our society without feeling some impact of organized religion. It is useful to keep in mind that the rejection of the tenants of organized religion by the “bad news” patient does not deny that the patient may have a powerful and active believe system that does not fall within mainstream religion.

I believe that should we fail to mention and acknowledge religion as a part of the “bad news” patient's life, then we are short changing the patient. One of our jobs in this short encounter is to help the patient open doors of support so they do not stand naked and defenseless in the wake of the “bad news.” I routinely ask “bad news” patients if we can offer some spiritual support that would be helpful. “When we are all together would be a good time to express spirituality so that each of us here can support that expression.”

I am sure that we should express to the patient the importance of not feeling alone in the face of “bad news.” Spirituality is to be encouraged as a protective force in the battle with the “bad news.” Our job duties as a first responder are to invite support and reassure. It is our responsibility to invite the “bad news” patient to be in touch with their religion and spiritual underpinning and reassure them that their spirituality and religious beliefs are welcome “in our house.”

It is predictable that any phenomenon as powerful as giving “bad news” has the capacity to spin out of control and produce undesirable or even tragic results. It is only recently that I have become aware that protection for the “bad news” patient and the clinician has become a critical component of giving “bad news.”

I know only from the local newspaper, accounts of a tragedy when a surgeon was giving “bad news” to a family member. In this catastrophic drama, the surgeon was shot and severely injured and the family member and his mother who was the “bad news” patient were killed at the hands of a family member. Could this have been prevented; I do not know. Fortunately, violence when giving “bad news” appears to be a rare phenomenon.

Never apologize for the information you have announced because it will further confirm your alliance with the disease itself. If you can apologize for the disease, then obviously you are responsible for the disease and the ravage that may occur from it.

It seems only courteous to show respect by using titles unless invited to do otherwise. You are conveying status to the “bad news” patient and others in the room when you use the appropriate title for the individual. People with status are less alienated. Years ago, I did not use the title of doctor with patients because I thought it was pretentious. I later found that the patients often want the reassurance that the title conveys.

From my vantage point of decades of practice I see that inadvertently and without malice, further barriers have evolved in the presenting of bad news. For many reasons, we as professional health care providers have become a collection of uncoordinated subcontractors. I am sure that the technical staff through training and repetition has developed the skills to the pinnacle of performance. I am equally sure that the procedures associated with the psychological aspects of healing the individual are likewise sharpened in our present minds. Over time, it appears to me that I have seen fewer primary providers, family medicine specialists, and internists in the hospital setting during the evening or particularly on weekends. These first line fine practitioners are much like the dominant female elephant in as much as the elephant holds the collective history of the tribe. The primary care doctor holds the collective history of the patient and their family.

I love the classic Hollywood extravaganzas from the halcion days of the romantic film. I have seen many of them often and remain captivated. They have served as a model of civilized living for tens of thousands. Many of these plots call for a tragic event usually the unexpected death of a central character. This event, not surprisingly, is met by shock and active grieving on the part of another central character; usually the love interest of the character that has just been lost.

In the drama, the person delivers the shocking news or at least a near bystander is always a physician who can instantly summons a nurse in a white uniform complete with a nurse's cap. The physician is powerfully insistent that this “bad news” person take a strong sedative to endure what has occurred. If the “bad news” person resists, the physician uses the power and status of his position to override the stated objection. The “bad news” person takes the two pills offered (always two pills). The person retires to their bed. We next see the “bad news” person emerging in the morning seemingly feeling much better and certainly in better control. Those pills must be well hidden and in extremely short supply as I have never been able to locate even one of them, and certainly not the required two.

Sedation appears to be the most common reason, which would be requested by the “bad news” patient and/or their entourage and family. Another reason is providing a medication for the “bad news” patient has become institutionalized as a step in the “bad news” protocol. The medication is given because the clinician really does believe the patient will feel better in the morning after a medication-induced sleep. This is such a compelling belief that it would seem so powerful as to override any argument to the contrary.

A set of arguments exists to argue against medicating the “bad news” patient. Unfortunately, as the well used folk saying goes “there is no such thing as a free lunch.” From the trauma literature, the grief literature, and other segments of mental health knowledge, it is compelling that the sooner and the more completely, adverse situation including receiving “bad news” is confronted without interference, the more completely the painful event is resolved. When time passes, the event takes on a mythology greater than the event and much harder to resolve.

We all know that emotions are aids in resolving the “bad news.” With the expression of emotion, wordless healing can take place. It is difficult for all of us to witness the “bad news” patient crying half screaming, writhing in their bed, and emotionally addressing unthinkable terrors. Should we medicate the patient, they are deprived of the participation in a productive process that is invaluable as the beginning of the “bad news” resolution process.

Should the level of psychic pain be unbearable, then medication should be provided without delay. It is well not to confuse physical pain with psychological pain as the intervention is remarkably different. Giving or receiving “bad news” is a rugged process and not one easily mastered.

Giving bad news is a collaborative venture including the “bad news” person, the caregiver, the loved ones, and the friendship system. For the “bad news” process to be useful, then we as clinicians will need to be vulnerable, a super listener, and willing to experiencing the discomfort of powerlessness.