Delivering bad news: How to help both messengers and patients

Psychologists typically see patients looking for help with understanding and coping with difficult situations in their lives. But sometimes psychologists—especially those who work in hospital settings—may learn of bad news that will dramatically affect a patient’s life before the patient is aware of it.

A health care team might be treating a wife hospitalized with covid whose husband just died of the same disease in another room, for instance. Perhaps the patient is a car crash survivor who is about to hear a loved one or a stranger was killed in the same accident. Or maybe a patient is about to learn they have a new disability or are dying.

Fortunately, said psychologist Megan Hosey, PhD, it’s typically the medical team’s job to share news about medical prognoses or impending death. And family members or other loved ones who know the patient well may be best suited to share nonmedical bad news, such as the death of a loved one. “The psychologist’s role is not to be the deliverer of bad news,” said Hosey, an assistant professor of physical medicine and rehabilitation and pulmonary and critical care at the Johns Hopkins University School of Medicine. That said, there’s plenty psychologists can do to help both the person delivering the bad news and the person receiving that information.

Psychologists should encourage those who are aware of the bad news to be honest with the patient about whatever happened or is expected to happen. “In the 1950s, it wasn’t all that uncommon for a doctor to tell a patient’s family that the patient had cancer but not tell the patient, with the idea that that was somehow protecting the patient,” said William Stiers, PhD, ABPP, an associate professor of physical medicine and rehabilitation at Hopkins. “That’s a really misguided, parentalistic act.” Even if done with the best intentions, dishonesty damages trust, said Stiers. It excludes people from participating in healing rituals, such as funerals. And most people are resilient, despite families’ beliefs that they will fall apart.

Plus, “people fill in the blanks when you don’t tell them anything,” said Arianna Timko, PsyD, a trauma psychologist at La Rabida Children’s Hospital in Chicago. Hospitalized children, for example, may worry they have been abandoned or just wonder where deceased loved ones are.

Psychologists can provide support on both sides of the bad news equation, according to Hosey. First, they can coach the bearers of bad news on how to deliver it in a clear, compassionate manner. Some psychologists will even offer to role-play the conversation ahead of time. Psychologists could also offer to be present in the room during the conversation to provide additional support and guidance.

Once the conversation has taken place, said Hosey, the patient may need help processing the news. Psychologists can assess how well patients understand what they’ve been told and how they’re coping with the news. Patients may also need help figuring out how to move forward despite loss. “The psychologist can start to open the door to what to do next to make life as full and meaningful as possible in the new context,” said Hosey. Patients may also need ongoing help from a psychologist as they work through grief, whether from the loss of a loved one, loss of a bodily function, or other sources of pain, she added.

In some situations, it is better to wait before sharing bad news. Say you have a patient with a traumatic brain injury who still doesn’t remember events day to day or even what year it is or where they are. If every day is Groundhog Day for the patient, said Stiers, it’s better to wait. “You don’t want to retraumatize someone every day,” he said. “You don’t want to provide information until patients are able to process and retain it.” Families may need the psychologist’s help deciding when a patient is alert enough to process the information, added Stiers.

“Let the patient drive the conversation,” said Hosey, noting that the person giving the bad news should let the patient decide how much information they are ready to hear. The person delivering the bad news should first ask the patient what they already know and ask if they have any questions, she suggests. “Some people want to hear everything; some really want to go one step at a time,” she said. The same goes for gory details about accidents or photos of the patient when severely injured or ill, she said.

It’s good to let families draw on their own cultural heritage as they communicate bad news, said Timko. That might mean encouraging families to use the words that make them most comfortable when it comes to describing where family members go after they die or how patients can continue to communicate or remain connected with them, she said.

But being clear is also important, adds Hosey. “Avoid euphemisms like ‘no longer with us,’ ‘passed on,’ and ‘not suffering anymore,’” she said. Such euphemisms can make comprehension difficult for patients with acute medical conditions and lingering cognitive challenges. “Euphemisms are harder to understand when you’re in an unfamiliar, emotionally charged situation,” said Hosey. “Using clear language helps cut through the emotional fog of these moments.”

To make sure young patients understand what’s going on, Timko works together with parents or other caregivers to decide what to share to help the child make sense of a loss without inundating them with unnecessary details. “You might say, ‘You were in an accident, and in the same accident Mommy got so hurt she died and she’s not coming back,’” said Timko. “A child doesn’t need to know exactly how she was hurt or whether she died on the scene or in the hospital.”

By offering guidance to the messengers and supporting the patient after the conversation takes place, psychologists can help avoid additional trauma. Said Timko, “This may be a moment the patient will remember forever.”