A. Outcomes may be uncertain
Determining the prognosis and forecasting the course of a chronic or serious illness is not a easy process(see module on prognostication).
The outcomes depend on multiple variables including but not limited to, nature and severity of illness, availability of treatment modalities that may effectively cure, alter the course or palliate an illness, patient’s coping strategies and availability of robust emotional, social, financial and spiritual support systems.
B. The stakes are high
The news about serious and or chronic illness has a life-altering effect on patients and often has grave implications.
“I will never see my son graduate.”
“I will never get to grow old with my beloved wife.”
“I will never see my grand kids.”
“I will not be able to give away my daughter during her wedding.”
“I am going to be a burden to my loved ones”
“I will never get a chance to prove myself.”
“This is all my fault.”
“Why me? What have I done to deserve this?”
“I will never get a chance to take that dream trip I have always wanted.”
“If only I had not been a couch potato. If only I had lost weight…….”
“Diabetes! My family curse strikes again!”
“It is all my fault!”
“This illness killed my father. Now I have it!”
“I am going to miss my family.”
“Oh, no! Who is going to take care of my kids? I am a single mom.”
“My baby will not remember me. She is too young to remember.”
“My kids are going to grow up without the love and support of a father.”
“What will my family do without me? Who will take care of them?”
“Who is going to protect my little ones? My husband is a alcoholic.”
“My ex-wife is going to get custody of the kids. She is not a nurturing person.”
“I have failed. Again.”
C. Emotions may run deep
When faced with a life altering illness, most patients experience grief. As shown above, patients react very deeply and primally to bad news about life altering illness. Patients with previous history of mental illness, patients with poor social and financial support systems are especially vulnerable.
D. Time is of the essence
- Immediate time pressure: Both patients and clinicians are subject to immediate time pressures.
- Clinicians typically have other competing priorities and typically do not have a lot of time to spend with individual patients.
- Breaking bad news and supporting the patient through that initial encounter is a process that will take time and it behooves the clinician to be mindful of this and specifically structure adequate time in their schedule.
- Competence is a great stress reliever. The clinician who is adequately trained in communication skills is more likely to break bad news both sensitively and efficiently.
- Patients and families too have to take time off from their everyday routine for a doctor’s appointment. It is well known that patients typically have to wait for significant periods of time in the clinic or the emergency room etc.
- If a clinician seems to be in a hurry and feels pressured for time, this urgency is likely to affect the patient and family and thus inhibits free flow of conversation.
- Longitudinal time constraints due to the illness:
- A diagnosis of serious life limiting illness alters the course of a patient’s life. Their life as they knew it (prior to the diagnosis of life limiting illness) is over. Many patients feel like they are racing against time. They often want to accomplish many important tasks but feel cheated as they now have to live with a life limiting illness.