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Back to Module 2: Communicating Bad News A Six Step Protocol

Using the Six Step Protocol in Other Situations

• When Language is a Barrier
• Communicating Prognosis
• Why Do Patients Ask about Prognosis?
• What to Do Before Responding to Patient Inquiries
• Responding to Inquiries about Prognosis
• Caregiver Communication

Using the Six Step Protocol in Other Situations

When Language is a Barrier

• Use a skilled translator who is:

• Familiar with medical terminology
• Comfortable translating bad news

• Meet with the translator before the interview to:

• Brief them on what will be said
• Reassure them their role is only to translate
• Verify that they will be comfortable translating the news you are about to give

• Avoid family as primary translators

• Confuses roles in family unit
• May raise issues of confidentiality
• Family members may not know how to translate medical concepts
• Family members may modify news to protect patient
• Instead, encourage family to:


• Supplement the primary translation
• Support patient and other family members

• During the interview:

• Sit in a triangular arrangement so that you can:


• Face and speak directly to the patient
• Yet still turn to look at the translator


• Speak in short segments, then give the translator time to convey the information
• Verify the patient’s and family’s understanding and check for an emotional response

• There are several services in North America that offer translation by telephone if there is no one directly available.

• See information on Medical Interpreters in Module 13: Cultural Issues

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Communicating Prognosis

Why Do Patients Ask about Prognosis?

• Patients frequently ask about prognosis

• There are many motivations for this request

• Some want to have a sense of their future so they can plan their lives

• Others are terrified and hope that you will reassure them

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What to Do Before Responding to Patient Inquiries

• Before directly answering their questions about prognosis, inquire about their reasons for asking. Questions might include:

• What are you expecting to happen?"


• "How specific do you want me to be?"


• What experiences have you had with others with a similar illness?"


• "What experiences have you had with others who have died?"


• "What do you hope/dream will happen?"


• "What is your nightmare about what will happen?"

• Consider the implications of the prognostic information you provide

• Patients who wish to plan their lives want information that is more detailed.


• Those who are terrified may do better with answers that are more general

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Responding to Inquiries about Prognosis

• Definitive answers, e.g., "You have 6 months to live," run the risk of producing...

• Disappointment, if the time proves to be less
• Anger or frustration, if you have underestimated the patient’s lifespan

• Consider responding by giving a range of time that encompasses an average life expectancy, such as:

• "Hours to days"
• "Days to weeks"
• "Weeks to months"
• "Months to years"

• Alternatively, indicate averages such as:

"One third of people will do well a year from now, half will live about 6 months; exactly what will happen for you, I don’t know."

• After giving a range, it may help to emphasize the limits of prediction by saying something like:

"What this will mean for you I can’t tell. We need to hope for the best, while we plan for the worst. We can’t predict surprises and should plan in case something happens. Over time we’ll have a better sense over time how things will evolve for you."

• Always caution patients and families that unexpected surprises can happen

• Suggest that they get their affairs in order so they won’t be so vulnerable if something unexpected does occur


• Reassure them that you will be available to them to deal with issues and support them throughout their illness, whatever happens


• Help clarify what can be realistically expected and distinguish this from what might be wished for, or what is most feared


• Identify the miraculous for what it is—something outside of usual experience that happens exceedingly rarely

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Caregiver Communication

• The sharing of information among caregivers is critical

• Maintain a chart or log book close to the patient that can be shared by all who provide care, including physicians

• Pooled information can help:

• Facilitate a continuous plan of care
• Avoid constant repetition of questions
• Avoid unwanted activities

• It will be most effective if the chart or log book includes:

• Goals for care
• Treatment choices
• What to do in an emergency
• Likes and dislikes
• Things to do and or not to do
• Contact information for family, physicians, and other members of the interdisciplinary team

• Ensure that data is recorded accurately and accessible to everyone

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