Running Header: PALLIATIVE COMMUNICATION

The When and How of Palliative Communication

Amanda Hubbard, RN
Ferris State University

Part I

How do you deliver bad news? Health care providers are often expected to deliver bad
news without a dedicated curriculum regarding how to perform this difficult and complicated
portion of medical practice (Jacques, 2011). When delivering bad news, you have to be able to
assess the patients and familys emotional state, what stage of grieving they are in, and be
understandable when delivering information. If you are not trained in this area, the
communication between caregivers, patients, and their families break down ending in a situation
where trust and faith are lacking in the relationship.
How and when do doctors tell the patients and their families that there is no longer a
curable direction for their illness? Are there differences in the approach if say, you deal with
terminal illness on a daily basis compared to someone who does not? When I started this paper I
thought that there would be some sort of guideline that doctors follow when delivering bad news
to patients and their families. Boy was I wrong! Every doctor has a different way of delivering
the news. Most have no formal training in this type of communication; it is learned on the job by
observing other more educated doctors.
The reason I am researching this question has to do with my best friends dad. He passed
away in January with the doctors saying that he could overcome his illness. He was diagnosed
with congestive heart failure and had an ejection fraction of less than 20%. In others words, his
heart was failing (due to the previous damage caused by multiple myocardial infarctions or heart
attacks), causing him to drown in his own bodily fluids. The doctors gave the family hope, in that
he would survive all of his health issues. After a week of intensive care he passed away, and that

is when it came out that it was a losing battle from the start. His heart was not strong enough to
sustain his life.
End-of-life communication may be important to people currently going through an event
of their own, but should be of the utmost importance to the doctors and nurses that are taking
care of patients with unfavorable life expectancies. Communication is the heart of every
relationship built in the medical field.
Part II
Palliative care is not the same as hospice care. Hospice care does not allow curative
measures to be taken, whereas palliative care is aimed at comfort measures but does allow
curative actions to be performed (Ragan, 2003). Hospice care is usually started when the
decision is made to forgo further lifesaving treatments and the patient has six months to a year of
life to live. Palliative care is now being started at the time of diagnosis of some terminal
illnesses. Both aim to provide comfort and keep patients pain free, but palliative care takes the
whole person and their spiritual beliefs into account, not just the physical aspects that come from
the disease process. According to Bharadwaj, Shinde, Lill, and Schwarz (2011), There is an
increasing body of evidence that indicates that involvement of palliative care not only improves
quality of life but also prolongs life as well.
Part III
I interviewed Dr. Christopher Ash, DO, a general surgeon and Dr. Douglas Iddings, DO,
a certified cancer surgeon at Genesys Regional Medical Center in Grand Blanc, Michigan. These
interviews gave me two different perspectives to answer my question. It gave me a perspective
from a doctor who deals with terminal cancer diagnoses on a daily basis, and a perspective from

a doctor who does not deal with these concerns daily. I chose the interview over a survey,
because I thought that it would be easier to gauge emotional responses.
I carried out my interviews in the operating room setting. In both cases the doctors were
aware that I wanted to interview them prior to coming into the operating room. Both doctors
walked me through the history of the patient and what they thought their outcomes would be. In
both cases, the outcomes were not hopeful. After the surgeries, both doctors sat down with me
and walked me through how they tell the patient and/or family that despite their attempts, the life
expectancy outcomes were not promising. While conducting these interviews, I noticed that there
were many similarities in the way these physicians viewed the delivering of bad news.
Part IV
When I interviewed Dr. Ash, he had just come from delivering bad news to the family of
a patient that presented to the emergency room with abdominal pain. The patient turned out to
have massive amounts of ischemic (dead) bowel and was not expected to make it through the
next few days. With Dr. Iddingss interview, he was debulking an abdominal carcinoma on a
patient with metastatic disease processes. Neither patient had life expectancies beyond six
months.
The first question I asked of both physicians was, when do you tell a patient and or their
family member that there is nothing left that you can do? Both doctors had very different
responses. Dr. Iddings stated, That is a bad question. There is always something that can be
done. There are palliative treatments such as chemotherapy and radiation, and depending on the
extent of the disease and the patients and familys wishes, there is always hospice. Dr. Ash

stated that, You tell them as soon as you know and as events unfold you continue to inform
them.
When asked how you tell a patient that there is nothing left that can be done, both
doctors had similar approaches. According to Dr. Ash, you keep the first conversation brief and
to the point. Most patients and families do not hear much beyond the initial diagnosis. Dr.
Iddings stated, Truthfully and as honestly as possible.
There are some considerations you have to take when discussing medical issues with
patients and their families. Educational and emotional level are the two most important. You
have to be able to speak on their level in order to get the point across. Both doctors agreed that
you have to give the patients and their families the news in real time and that you have to be
truthful and honest with them. When delivering bad news and emotions are high, things can get
dangerous for the people in the room. Having the staff alert and support people available helps to
ease the tensions and allow the conversation to continue.
So when do the doctors bring up the issue of palliative care and/or hospice? Both agreed
it should be brought up after the initial shock of the diagnosis has had time to sink in. You cannot
talk to a patient and their family about long term goals until they have had time to digest and deal
with the diagnosis. According to Ragan (2003),
Palliative care must begin early in the course of terminal or life-threatening (or even
quality-of-life-threatening) disease. Whether at diagnosis or recurrence, patients must be
presented the option of palliative medicine (in addition to or in place of active, curative
medical treatment).

Both doctors agreed that the initial conversation is not the best time to bring up the topic of endof-life issues. If over the next few days the family has not brought up the subject, than as the
patient advocate you must have a conversation and decide what is best for the patient. According
to Dr. Ash, The patient and family lead the direction of the conversations, but as a professional
in the medical field, you are the one in control. According to Walsh and Nelson (2003):
(1) it is best to let the patient set the pace of the communication, with the physician telling
the patient everything he or she wants to know but rarely more; (2) it is useful and
necessary to reiterate the important information, thereby ensuring that it is understood
in the setting of stress, fear, confusion, or denial; (3) it is best, when addressing the
patients concerns, to determine all concerns before exploring one in depth; (4) patients
should be assured that the physician will remain involved; and (5) support should be
offered for continuing high-quality medical care, including an emphasis on quality of
life.
It used to be that and in some countries still is; wrong to tell a patient that they are going to die.
In the United States, patients have the right to know their diagnosis. All they want is open honest
communication in order to make an informed decision regarding their treatment options.
According to Alberts (2004), The most appropriate and informed decision will result from open,
candid discussion among the patient, family, and doctor, after realistic expectations have been
outlined.
What I found from my research and interviews is that there is no real training in end-oflife discussions for residents, and that everyone has a different viewpoint on how to break the
news to patients. All patients want, is the information in real time and open and honest answers

to their questions. I also found that doctors do view end-of-life discussions differently, but go by
many of the same principles when delivering the news. My question was tentatively answered in
the fact that I learned that most doctors will tell the patient as soon as they know the information.
As far as how doctors tell their patients, I believe I have a limited view. There are many more
doctors with various backgrounds. I believe that there are still very different views out there
depending on who you talk to. I believe that depending on ethnicity and possibly even gender,
viewpoints may differ. Dr. Iddings and Dr. Ash are only two views of how to deliver bad news.
The way their answers differed only proves that there are differences in attitudes depending on
whether you deal with delivering bad news on a daily basis or not.
Part V
My inquiry raised many more questions and also showed me where my inquiry question
and research methods could have benefited from some more work. The major question raised
was, why there is no formal training on delivering bad news. I should have worded my inquiry
question differently in order to elicit a better response from the doctors interviewed. I also should
have surveyed the doctors instead of interviewing them. I would have gotten a better idea of how
more doctors from different backgrounds would discuss end-of-life issues with their patients.
As for the future, I foresee more programs educating doctors and nurses in end-of-life
communication. I am actually looking at trying to start this as a service learning project for a
nursing class. I believe that everyone in the health care field could benefit from this kind of
training. Not only will the health care professionals benefit, but ultimately the patients and
family will, by having the healthcare team on the same page. It will lead to a better end-of-life
experience for everyone involved.

Appendix
When do you tell a patient and/or their family that there is nothing more you can do for them and
their illness?
Ash: As soon as you know. They dont hear much beyond initial diagnosis. Revisit the
diagnosis a day or two later and let them lead with their questions.
Iddings: That is a bad question. There is always something you can do. Palliative carechemo, radiation, surgery. Hospice.
How do you tell them
Ash: Honestly. In real time. Sequence of events. You give them the information, not your
perception or will. Keep things in a short term perspective, dont look too far ahead.
Iddings: Honest and truthful. No unnecessary procedures.
Are there any issues that you need to assess before you tell them?
Ash: Mental and emotional state. Educational level. You have to be able to deliver the
information in terms that they can understand.
Iddings: Emotional state. Things can become dangerous if you try to deliver bad news to
someone who is emotionally unstable.
Is there ever a point that you say enough is enough or do you leave it up to the patient to make
that decision?

Ash: You always leave it up tp the patient. The patient has to fight, the surgeon cant.
Iddings: It is always the patients decision.
What do you do for the patient after they have decided to forgo any more treatment?
Ash: Weekly visits until they decide to go to hospice or they pass.
Iddings: Point them in the direction needed. Hospice information and numbers. Or you set it
up before they leave the hospital or office.
Do you allow the residents to inform the patient or is that strictly something you do?
Ash: Residents are encouraged to be there to deliver the information. Their concern for the
most part is to get the orders written and get the patient through the night.
Iddings: I do not have residents that work under me. I do have fellows that work with me for
a month or two a year. They deliver the news with me. They are still learning and I allow
them to give information when I am present.

References
Alberts MD, Dave, and Lucy Godley, MD, PhD (2004). Clinical trials and end-of-life decision.
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Bharadwaj, Parag M.D., Arvind Shinde, M.D., Michael Lill, M.D., & Ernst R. Schwarz, M.D.,
Ph.D. (2011). Palliative care: It is time to move toward a comfort and cure model. Journal
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