Case Scenario

My 69-year-old male patient recently was diagnosed with metastatic cancer. The primary cancer has not been identified. The patient’s family is in shock and has indicated to me that they “want everything done to save his life.” I mentioned to the patient that the computed tomography scan showed cancer, and that I would like to meet with him and his family to discuss his care in greater detail. In the past, although not in the context of his own possible death, he often has dismissed persons who “can’t face reality.” Because the patient and his family might have different opinions on the subject, how should I handle the upcoming meeting?

Commentary

Communication training stresses that “breaking bad news” is more about listening and asking questions than it is about relaying information.¹ Most patients with metastatic cancer want to know about their prognosis; however, the desired extent, format, and timing of this information vary from patient to patient.² Assessing how well the patient has accepted his illness may help determine his willingness to know more about the prognosis. The most important question to ask a patient is a simple one but often is overlooked: “What is your understanding of this illness?” Let the patient answer this question in front of the protective family, especially if they have asked you not to mention the word cancer or hospice to the patient. The patient will demonstrate his degree of acceptance by how vague his response is. Follow your patient’s lead. If he has a high degree of denial, it is best to continue the discussion on another day when he is more willing to talk about his illness. Blunt, direct questions from the patient signal a readiness to hear the information about his illness. Resist the temptation to confuse the patient with too many facts or complicated information. A physician also should never attempt to force the patient to accept his condition. Likewise, do not interrupt him; be polite and considerate.

If an urgent intervention is needed, and denial becomes an obstacle to appropriate medical care, one technique is to say something similar to, “I’m concerned that you do not realize the seriousness of your condition.” If the patient responds well, he may be receptive to hearing about his condition. If the patient is not responsive to your comment (e.g., he has a blank stare or attempts to change the subject) he may be in profound denial and you should meet separately with the family to discuss the urgency of treatment. If your office has an ethics committee or palliative care consultation team, this group should be consulted.

The next question you should ask the patient is: “What would you like to know about your illness?” More than 85 percent of patients will request further details or explanation after receiving a prognosis; most commonly, such desired information includes symptoms, treatment options, and life expectancy.² Again, keep the medical information as simple and brief as possible. In my experience, patients will not retain much of this information, and some patients will reconsider their desire to know the details of their illness. In this event, you can ask the patient whom in the family you should give frank information to regarding his or her condition.

Maintaining hope is important to the patient and vital to the therapeutic alliance between you and your patient. However, it also is important not to give your patient or his family false hope. Hope of being cured, or of returning to a previous level of health and well-being, is unrealistic for a patient with metastatic cancer. By reframing the clinical situation positively, you can give the patient more realistic expectations while preserving hope.³ Often, simply stating what the next steps will be can reassure the patient as well as promise ongoing attentive medical care (e.g., competent care, nonabandonment, protection of the patient’s informed choices) based on the patient’s individual values, preferences, and goals.

The patient and his family may not seem ready to hear about a prognosis, but that does not mean you cannot address the issue. A patient’s first question after receiving bad news from his physician is usually about how much time he has left; however, this question often remains unasked. The questions most often articulated concern the patient’s ability to continue working, the impact his illness will have on loved ones, and what he should expect next. By focusing on maintaining quality of life, you can help the patient redirect his thoughts of dying toward looking forward to the time he has left (e.g., enjoying the next family event, holiday celebration, or favorite activity).