How ODs should break bad news to patients

Orlando-Breaking bad news is one of an optometrist’s toughest tasks, yet medical instruction typically grazes the surface of formal preparation for it. Without adequate educational groundwork, the distress of delivering bad news may lead to emotional detachment between optometrists and their patients.

Jay Lytle, OD, FAAO of Columbus, OH, discussed physician burnout at the American Academy of Optometry 2019 annual meeting. Armed with optometry-focused best practices and evidence-based clinical methods, Dr. Lytle equipped fellow optometrists with tools to improve patient satisfaction and prevent the negative effects of physician burnout as a result of delivering bad news.

What is bad news?
According to Dr. Lytle, bad news is “any news that negatively alters a patient’s view of his or her future.” In optometry, this may refer to a glaucoma or vision loss diagnosis. It may also denote the news that a patient’s favorite eyeglasses frame is discontinued or that he is not a candidate for an elective surgery he needs.

While bad news is typically associated with a terminal diagnosis, it may also refer to a finding that impedes on a patient’s lifestyle in any negative way.

Most physicians report that they deliver bad news one to two times a week, but Dr. Lytle says that number is probably higher.

“The person who determines whether news is bad or not is the patient,” Dr. Lytle says.

Why is it so difficult to break bad news?
ODs face many difficulties associated with breaking bad news. Until recently, it was common practice to conceal a terminal diagnosis from the patient. That practice has changed and today, doctors have a legal obligation to deliver bad news.

“It’s our responsibility,” Dr. Lytle says.

One of the most common concerns is that, upon hearing bad news, patients deteriorate emotionally or physically.

In addition to that, breaking bad news is unpleasant. Many physicians don’t want to remove hope from their patients, and there may be uncertainty around how to effectively communicate bad news.

“Physicians may feel guilty-as if they have failed a patient,” Dr. Lytle says. “They could also be worried about staying on schedule with the rest of their patients.”

Research shows that physicians tend to withhold emotions or become overly optimistic when delivering bad news. But with proper education in evidence-based clinical methods like ABCDE and SPIKES, physicians can avoid stress and burnout.

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How should bad news be delivered?
ABCDE and SPIKES are step-by-step protocols for physicians to follow in order to communicate bad news effectively.

ABCDE stands for:
• Advance preparation
• Build therapeutic environment
• Communicate well
• Deal with patient reaction
• Encourage emotions

SPIKES stands for:
• Setting up interview
• Patient’s perception
• Invitation from patient
• Knowledge and information
• Emotions and empathy
• Strategy and summary

Dr. Lytle combined the most important ideas from each method to deliver a guide for ODs. 

The first step in delivering bad news is to thoroughly review patient records and arrange for a private, comfortable setting. Optometrists should negate interruptions and allow patients to have support members present when receiving bad news.

“It is important to introduce yourself to every person present, even babies,” Dr. Lytle says. “Doing so will reinforce the family unit, and you will appear more likeable to the patient.”

The next step is to sit in a neutral body position with your feet flat on the floor and palms face down in your lap.

“Research shows that when we can see someone’s hands, we trust him more because we know he is not hiding anything,” Dr. Lytle says.

From there, ODs should ask the patient to tell them what she knows of her medical situation and wait for an invite to hear more by asking an open-ended question such as, “Is this a good time?”

“Asking such a question allows the patient to take responsibility of the news,” Dr. Lytle says.

Address emotions with empathy
The most challenging part of delivering bad news is sharing it with empathy.

“Don’t be afraid to be silent,” Dr. Lytle says. “Offer tissues. One of the best ways to handle someone who is crying is to allow silence and space for her to let it out.”

Best practices advise ODs identify and explore the patient’s emotion, then make a connecting statement to validate it, such as “you are correct to think that way.”

“We often don’t do this part; the clinic gets busy, and we forget. But it’s so important,” Dr. Lytle says.

Share a treatment strategy
The final steps in delivering bad news are to summarize what you told the patient and when he is ready, create a clear plan that offers treatment options. Make sure the patient knows how to reach you to avoid feelings of isolation.

“You can apply this script to just about any bad news discussion,” Dr. Lytle says. “The goal is that one day the patient can echo the words of the orphan Oliver Twist who said that when he looked back on his trials, and all the negative experiences of his life, that his 'grief arose... so softened, and clothed in such sweet and tender recollections, that it became a solemn pleasure, and lost all character of pain.'"

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