Focuses on three models for informing patients of bad news. The focus is on the Timing, Listening, and Understanding (TLC) model, and includes some common questions about its application. Virtually all physicians understand that it is a patient’s right to be informed, and there is continuing evidence that bad news about a diagnosis of cancer helps give patients and families time to prepare and focus on what is left to do in the meantime. However, as Dr. Nahill explains, one of the major challenges in giving bad news is the lack of formal curriculum and education in the field. Although there have been some promising changes in the field at the undergraduate medical school level and in residency training, most physicians are still unprepared to inform patients of bad news. A study by Braddock et al. investigated the extent to which a group of 125 medical and surgical primary care physicians and their patients participated in informed decision making (IMD), a process in which patients actively explore and fully understand IDM. The study classified decisions into three categories based on “impact on patients,” “degree of medical consensus,” and “nature of outcomes”: basic, moderate, and complex. The study found that physicians were poorly equipped to handle many aspects of IDM. They were adept at describing the decision itself (71 percent), but when assessing whether to ask patients for understanding, only 1.5 percent completed it on average. Only 1 in 5 patients were given the opportunity to express their personal opinions in terms of joint participation and guiding patients’ treatment choices. 2. Basic models of physician-patient communication There are three basic models of physician-patient communication: The first is the physician-centered model. In this model, the physician takes the lead, asks the patient all questions and decides what should be done. In this model the physician makes decisions independently of the patient and there is little two-way communication. The second is where choice and communication is left entirely to the patient. In this laissez-faire model, the physician’s role is simply to provide information and let the patient make his or her own decisions about what to do. Communication in this model is only fair, and the patient fails to achieve the purpose of the visit. The third model is the shared model, in which there is a process of negotiation and compromise between the patient and the doctor. Decision making and responsibility are shared in this model. Therefore, the communication is adequate. 3. The impact of bad diagnostic news and disease recurrence on patients Bad diagnostic information often shocks patients. There is ample psychological and physiological evidence suggesting that information processing abilities do not work for a short period of time after bad information is obtained. Therefore, a lengthy explanation of treatment options and approaches at this time is usually not a good approach, as patients will neither remember them well nor articulate them well. A period of silence after the message has been delivered helps the patient to accept the messages and begin to understand their meaning. Informing about a relapse is also often challenging for patients. After experiencing one or more therapeutic measures and their adverse effects, the news of a relapse may put the patient in a more vulnerable psychological state. The use of silence and nonverbal empathic behavior is key to helping patients not give up on themselves and find hope in the face of relapsed disease. 4. The TLC Model for Communicating with Older Oncology Patients In order to effectively communicate with older oncology patients, there are several factors that must be considered. First, physicians must consider the timing of providing information and anticipate the impact on patients and their families; second, effective communication depends on good listening and conversation skills; and finally, they must ensure that patients not only hear, but must understand the information provided. 5. Timing of treatment discussion Early discussion of potential risks of treatment or possible treatment failure is important for effective communication. During the diagnostic period of a patient’s condition, it is useful to state why a particular test or procedure is being performed, for example, “It is recommended that you have a blood test because your symptoms may be caused by a more serious hematologic tumor than anemia. the results are positive, an early warning about the diagnosis can often make it easier for patients to accept the bad news. Readiness: It is important to tailor the way bad news is told and discussed to the readiness of the patient and his or her family. Just as the shared participation model allows for good communication, the best results depend on the balance between the readiness and willingness of the provider and the patient to receive bad news. Even if time is at a premium (e.g., in an intensive care unit), patients should be given a few minutes or hours, if possible, to be prepared to receive bad news and participate in the discussion. Simple questions such as “Are you ready to discuss your test results and treatment with me now? ” or “How would you like to discuss your test results? Are you ready to get all the information now or 2-3 times later?” These types of questions will help establish a platform for discussion. Family members: In general, it is positive and beneficial to have family members present when giving bad news or having a treatment discussion, especially for older patients. Some studies have shown that having a family member present takes up more time than discussing with the patient alone, but this extra time allows the patient to better understand the condition and reduces follow-up visits. It is important to determine if the patient is willing to have a family member present, and the decision should be left to the patient. Barriers: Barriers to scheduling treatment discussions include physical, geographic, and psychosocial factors. Older patients often have physical limitations, such as hearing loss, that affect the quality of the discussion. It is important to be aware of these potential barriers to communication, such as the distance of the communicator, voice pitch and volume modulation, and conformity to the patient’s physical comfort. Geographic factors can also have an impact. Scheduling visits on convenient days and times will alleviate patient anxiety and increase the likelihood of on-time emergencies. Finally, attention to psychological and social issues is also important in determining the practicalities of the discussion. Support services provided by a social worker, family therapist or psychologist are often helpful in communicating with patients and their families who are having difficulty dealing with their problems. Teamwork of professionals is key. 6. leaning Listening The key to guiding the narrative thread is active listening on the part of the health care provider. Evidence suggests that using this approach takes no more time than traditional, illness-oriented communication. Here are a few strategies to improve listening skills for physicians to consider. Avoid interruptions Interruptions by physicians are an important source of patient dissatisfaction and can lead to immature diagnoses, tests, and treatment recommendations. In the elderly population, there is evidence that patients rarely provide additional information after being interrupted. If patients are given ample opportunity to tell their stories, some medical outcomes may change as a result. A study conducted by the Headache Study Group showed that the single factor most associated with the regression of chronic headache symptoms at 1 year was “the patient’s perception of having sufficient opportunity to express concerns to the treating physician. 8. Questions Open-ended questions can invite patient participation and dialogue. If used appropriately, they can help get to the heart of the patient’s concerns quickly and effectively. Questions such as “Can you tell me more about your pain? ” or “Why exactly have you become so averse to chemotherapy? ” will encourage patients to elaborate on their experiences in a narrative way. Another approach is to simply repeat the last few words the patient mentions; for example, if the patient has just said “I have no appetite,” open-ended feedback could be “Do you have no appetite? “Although it may seem inefficient and time-consuming to give the patient control of the communication through open-ended questions, research suggests that the extra time spent is not really that much and is almost negligible. 9. clarify Patients who have received bad news or are concerned about bad news sometimes lack understanding or show resistance to the status quo. An effective strategy is the clarification of information provided by the patient. Statements such as “Let me see if I have this right ……” or “Let me make a better understanding of what you are saying about your feelings …… ” will help guide the patient to clarify issues that are difficult to understand or allow the doctor to understand his or her ambivalence. Clarification of information, opinions and feelings can help in better decision-making. 10. Active listening Patients will feel supported and understood after they feel that the physician is reporting active interest in their concerns and efforts. Leaning in, making eye contact, nodding, and giving out messages such as “I’m sorry,” suggest that patients are being listened to and understood, thus creating a space for shared concerns. Physical contact can also be used in conjunction with active listening, however, given gender and culture, the use of contact is more complex and challenging than other modalities. Many physicians take for granted that what they say and what the patient hears and understands are exactly the same thing. If a patient is experiencing psychological and emotional depression when given bad news or making treatment decisions, there is good reason to ensure that communication is accurate and effective. Statements such as “Please tell me what you have heard about your illness so that I can confirm that I am clear” can help test the patient’s understanding. When understanding is incorrect or incomplete and distorted, the physician can “fix” and fill in the gaps. 12. The doctor needs to meet the goals related to understanding Completeness: Make sure you have the entire narrative line and understand the patient’s core concerns. Ask “Is there anything else you want to clarify?” can help identify gaps and incompleteness in the story. Emotion: It is important to be responsive to the patient’s emotions. A study by Suchman et al. showed that physicians did not often use empathy as a tool, preferring instead to focus on facts rather than emotions. A study by McGuire et al. showed empathy to be an effective tool. Planning: Patients who have been told they have cancer or are experiencing a recurrence are likely to need to make short- and long-term plans. For example, asking patients how they will return home from the clinic, how they will inform family members, and discussing the support they will need in the following 24-48 hours will help reduce anxiety about the unknown and can improve the doctor-patient relationship during treatment. 13. Strategies to improve patient understanding Review: When highly controlled and complex information is being shared, it is useful to occasionally pause and review what has gone before. Although the principle of casual conversation is not to repeat to the other person what is known or to speculate about what is known, when faced with bad news, “repetition” is both appropriate and necessary for complete and accurate communication. Summarizing is a form of repetition that is often easily accepted by patients, especially older patients. Encourage questions: Another effective strategy that can be used for summarizing purposes is to encourage questions. It is important to encourage questions throughout the communication. If a question comes to the patient’s mind in a particular context, it is difficult to get the patient to hold the question until the end of the communication because the context of the question has changed completely. It is also helpful to encourage patients and families to write down questions as they communicate. If many questions are inconvenient to answer within the allotted time, prioritize and grade the questions. 14. Common Challenges in Applying the TLC Model Fear of Blame Perhaps the greatest challenge in giving bad news is the fear of blame. To quote Antigone from 44 BC, “No one likes the bearer of bad news,” suggesting that the bearer of bad news has been viewed negatively for a thousand years. In addition, it may be that many physicians believe that telling bad news when it is absolutely certain reduces patient anxiety during the diagnosis. This is especially true when the result is negative. In addition, patients often claim to be stunned when they learn bad news. They said that they never received any indication from the doctor that something might be wrong, that the tests were routine, and that there was never any discussion of “what would it mean if the results came back positive?” There was never any discussion of “what would it mean if it came back positive? These patients claim that the lack of early warning of the possibility of a malignant diagnosis makes the diagnosis more difficult to accept. Is the physician doing this for fear of blame, or does it represent a form of altruistic attention to protect the patient from unnecessary harm? Clearly, this is an important challenge when applying the TLC model. 15. Lack of relevant standards Another challenge is the lack of a gold standard for assessing behavior. A recent literature review on informing bad news conducted by Ptacek et al. showed that out of more than 400 studies, only a few were based on validated or semi-validated methods. The authors conclude that there is no gold standard for the way bad news is communicated, and that published articles generally take the form of personal opinions and clinical anecdotes. In this context, physicians may have that doubt about how to proceed and evaluate their actions. The American College of Physicians, the American Society of Clinical Oncology, and others have proposed some consensus “interim” standards. Although these standards do not represent the gold standard from a research perspective, they can be helpful in providing advice on how to proceed in the event of bad news or a medical emergency. They are helpful in providing ideas for giving bad news or discussing palliative care and can serve as a starting point and reference point for evaluating the skills and abilities of individuals in this field. 16. Strong emotional reactions Potentially triggering strong emotions in patients and/or physicians is also one of the challenges. Patients often show strong emotional reactions when being told bad news, ranging from nervousness to hysteria. Knowing how to deal with strong emotional reactions is especially important in delivering bad news. Strong emotional reactions can be overwhelming and embarrassing to physicians. However, while the traditional medical perspective teaches physicians to be “caringly detached” or “emotionally neutral” when dealing with strong emotional reactions from patients, the more current view is that the strength of the emotional reaction is what is needed to determine the appropriateness of professional behavior. In this model, the appropriateness of professional behavior is judged by the impact of that behavior on the patient and the physician-patient relationship. If the physician is so emotionally driven that he or she is unable to think about the patient or if the patient in turn takes care of the physician’s emotions, then the behavior is unprofessional. Crying together can be considered ethical and professional if it helps the patient cope more effectively with impending death and family matters. Consulting and discussing with a colleague in the face of a patient’s strong emotional reaction is not only to clarify the matter, but also to help the emotional reaction to be controlled by another professional in time to avoid the sense of isolation and loneliness generated by the loss of self. 17. Facing death The last challenge is the presentation of the fate of the patient’s death. It is well known that usually physicians in a bad mood will lead to aggravation of the patient’s disease. This happens partly because they are afraid and disgusted with the final outcome. When treating elderly oncology patients, this situation can be complicated by other circumstances, such as other family members of the physician who may be in the same situation as their patient. Talking to patients about death can be particularly difficult in such situations. In the latter part of a physician’s career, the focus may shift from the older family member who has died to his or her own death and the meaning of that death. This response can therefore also inhibit a physician’s ability to communicate effectively with patients who have learned bad news or are dying. A series of medical education courses (CME) is available on how to deal with the fate of an individual’s death. In addition, the American College of Physicians conducts seminars or courses to help physicians understand the potential barriers to communicating with patients in the final stages of life. Finally, organizations such as Balint’s, which facilitate discussion, can be helpful in raising personal awareness and providing discussion of clinical matters. 18. Common reactions of physicians It would be useful to know the 5 reactions of physicians. Reflex: A statement made by a physician when observing a patient’s emotional response. E.g., “You look depressed.” Rationalization: Similar to “reflex” but also includes statements that are reasonable and acceptable. For example, “Anyone in your situation would be upset.” Personal support: A statement that shows that the doctor intends to help and support the patient. E.g., “I am willing to help you in any way I can.” Partnership: A statement indicating the physician’s willingness to work with the patient to solve the problem. E.g., “I am eager to work with you to develop a treatment plan that best meets your requirements.” Respect: Acknowledges the patient’s struggle and includes concern and positive attention. For example, “You have done an excellent job in dealing with such a very difficult situation.” 19. Summary For physicians who must communicate with patients and their families, there are many challenges to face such as ageism, lack of training, fear of one’s mortal fate, and the perception of bad news as giving up or the patient’s disease defeating. Recent research has created a new context for communication models such as the TLC model, which views bad news as a portal to personal growth and dignity at the clinical time-including a commitment to freedom from pain and unnecessary suffering at the time of death and to a deepening and strengthening doctor-patient relationship at the end of life. All patients’ families should be told that patients do not die of fright, only of misdiagnosis and malpractice. And crucially, the closest and most beloved relatives may end up being the ones responsible for delayed treatment.