Ripping off the bandage: Mastering bad news delivery in veterinary medicine

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As part of the curriculum, client communication, and specifically the delivery of unwelcome news is now being formally taught to veterinary students. This is a progressive change that has taken place under the directive of the American Veterinary Medical Association Council on Education over the past 10 to 20 years. Previously, most veterinarians had to master delivering bad news through trial and error. Although this skill comes more easily to some of us than others, the reality is that “on-the-job training” for this can be traumatizing. Many of us have coped by postponing these dreaded “bad news” conversations.

We are often reluctant to upset clients with a terminal or scary diagnosis until it has been fully confirmed. This is understandable, but rarely are we absolutely sure of a terminal diagnosis or of how long the patient may have to live. Because of high costs and/or treatment invasiveness, we seldom have the benefit of the advanced diagnostics afforded in human medicine and frequently must narrow down the diagnosis or make an educated guess. The good news is that in these cases, we usually have a good idea of what is wrong with the patient. So why do we sometimes wait to speak or choose to refer a client who is not interested in advanced care? Why might we send them home with palliative medications but not inform them that their pets’ time is short? Why do we shrink from our job of preparing clients for life’s devastating events? Why don’t we guide them through the end of an animal’s life as well as through the previous good years?

“Having to be the bad guy can be very draining,” according to Ryane Englar, DVM, DABVP (canine and feline practice), who delivered a lecture titled “Bad News Delivery: Why Are We So Bad at It?” at the dvm360® Fetch conference in Kansas City. Bad news conversations can involve medical errors, the loss of a patient, difficult discussions about money, an unexpected terminal diagnosis in a clinically normal pet, or euthanizing animals because of behavioral problems. How can we improve our skills and decrease our anxiety around conversations like these?

First, as Dr Englar points out, we must realize that we’re not alone in terms of the guilt, doubt, and fear that these situations engender. We are all afraid of how clients might react. They might blame us, cry, become angry, even retaliate. We may fear saying the wrong thing and making the matter worse. We may fear that we’re wrong, and also that we’re right. If we’ve made a mistake, we may fear all these things plus feel guilty and ashamed. If we are not confident about our diagnosis, we may fear that we’re wrong, and if we are confident but have no proof, we may fear that the client will not believe us or conclude that they’ve wasted their money.

We are in good company, not just among veterinarians but among all medical specialists. In human medicine, end-of-life discussions are even more critical, as the client is also the patient. But even MDs avoid the topic more often than not when dealing with the terminally ill, and formal training in this area is a relatively recent development. The problem is multifactorial, but essentially doctors “worry more about being overly pessimistic than overly optimistic” and rely on hope as a plan.¹ The results are that the patient and family are not prepared for the loss or for what death will be like. In a study called Coping with Cancer,² one-third of patients were given a palliative care specialist—essentially, someone to talk to. These patients experienced less suffering, less CPR, fewer visits to the emergency room, and were dramatically less costly to treat at the end of their lives. Their relatives were better prepared for the loss and for the decisions that had to be made. It wasn’t the details that made a difference, it was the conversation. As Atul Gawande puts it, “If end-of-life discussions were an experimental drug, the FDA would approve it.”²

It also helps to recognize the way bad news is delivered and received impacts both listener and messenger. Thus, it impacts us as veterinarians. But structure can be our friend in scary situations. Dr Englar recommends setting up a structured approach to have the best impact. Check in with yourself first, she points out, breathe (we forget), and pause. Ask yourself whether you’re in the right frame of mind, can focus on the client’s needs, and put them before your own. If not, take some time to center yourself.

Then, check in with the client. To accomplish this, we can modify the mnemonic SPIKES model used in human medicine.

SPIKES model

SETTING

Pick a place that is private and quiet for a face-to-face delivery of bad news, or find a telephone away from noise and interruptions (but only if a phone call cannot be avoided). Set aside time and ask the client for permission: Is this a good time to talk about Fluffy’s results? Tell them you need their undivided attention or schedule a time when this is possible. Look them in the eye if you’re meeting in person. It takes longer to share things over the phone than in person because you’re unable to interpret body language. It also takes longer to share information when the client is distracted because you may have to discuss the same thing twice.

PERSPECTIVE

Think about how the client views the situation. If the client is at home, how do they think their pet is doing? Clients often will not hear what we’re saying unless we first address what’s on their minds. Ask “What are you most concerned about?” “Did you think Fluffy wasn’t doing well?” Let them share their thoughts. This way, before giving them the news, you open a line of communication that can lead to a better, in-depth conversation or a shorter explanation later. If it is a surprise diagnosis, you can shorten this part to avoid undue client anxiety, but don’t just “dump the bad news.”

INFORMATION SHARING

Giving the diagnosis is the next step. Begin by delivering a “warning shot.” We each have our own way of saying the same thing. Some sample warning shots include:

“I’m afraid that I don’t have good news to report.”

“What I’m about to share with you is really important.”

“I need to talk to you about something serious.”

“I share your concerns; I am really worried about Fluffy, too.”

“This isn’t the news we were hoping for.”

Relay the news, then pause to let clients absorb it. It is important to pause for as long as they need.

KNOWLEDGE

At this point, you can discuss what you know about the condition. In the 1990s, medical ethicists Ezekiel and Linda Emanuel described 4 different ways of talking about a diagnosis or medical choice in human medicine: paternal, informative, deliberative, and interpretive.³ The paternal approach directs people to do what you want them to do while providing little information; the informative gives them all the details of the diagnosis and the medications and allows them to choose what to do; in deliberative mode, the doctor acts as a friend and makes specific recommendations; and interpretive combines information and direction, with the doctor acting as an advisor (not a friend) and the client making the choices. Far too often we use the informative method, overwhelming clients with facts and options but offering no direction. The better strategy is likely the interpretive: alternately informing and listening so that you can best guide clients by answering their questions. Let people know that you are worried, then “ask, tell, ask” as you deliver bad news. Ask what the client wants to know, answer the question, then ask whether they understood. This approach is now known as “shared decision-making” and seems to be the best way to assist people at times like these, but it requires a conversation. What does this mean for the pet? How much will it cost? What are the treatment options? How much time is this going to take? Is the condition curable? What is the goal of treatment? If not curative, is it palliative? Will it be painful? Will it significantly impact the animal’s lifespan? Is the testing complete? Also specify what you don’t yet know.

EMPATHIZE

How we handle the situation depends on our personal style and on how the client is responding to the news. Many of us struggle here. However, there are 2 main ways of empathizing. Cognitive empathy involves understanding where the client is coming from. You may or may not agree, but you don’t have to feel what the client feels. You’re simply acknowledging it. Emotional empathy, on the other hand, means that you are putting yourself in the client’s shoes and trying to appreciate in every way what it is like to be them.

Cognitive empathy is genuine, but it’s not as draining as emotional empathy and is easier to display. You may verbalize it to the client by saying, “I’m not you and I do not know what you are feeling, but I can understand how or why you might feel this way,” says Dr Englar.

Emotional empathy, on the other hand, is raw and more difficult to sustain. If experienced regularly, it can drain you and eventually contribute to compassion fatigue. If you do go there—and there are some clients who may draw emotional empathy out of us more than others, such as the long-term client whose dog we’ve cared for since puppyhood—know how to get yourself back from the brink of emotional exhaustion. Know your limits.

Empathy can be displayed in words: “What can I do to help?” “This must be really hard; help me to better understand your situation.” “I care, what do you need right now?” Don’t give advice and don’t change the subject. Never interrupt the speaker. Try not to invalidate the speaker’s feelings. Don’t end the conversation. Let them share. Empathy is deeper than sympathy, and it is interactive. Those who struggle to display empathy verbally may choose to show it through actions and gestures, like simply sitting beside the person who is grieving.

SUMMARIZE AND STRATEGIZE

This is the final step. Where do we go from here? Do you need to call someone, or get back to me? What do you need that will help you with the next step? Clients may not even be ready to talk about the next steps, but you should at least leave the door open for them to discuss the plan at their convenience. You may make an offer of next steps as a gesture of goodwill; it can be something as simple as a phone call to check back with them in the near future.

Takeaways: being upfront with clients

How do you communicate with clients without making them feel bad? Well, the goal is to make bad news survivable, not pain-free. It is going to hurt. Clients need us to hold their hands during the patient’s life, and this includes the end. They expect it.

Working in the ER, I am delivering bad news multiple times a day and, in some cases, all day long. Much of the bad news I relay has already been diagnosed at the pet’s regular hospital, but either it has not gotten through, was diluted and minimized, or wasn’t addressed at all.

Guidance at the end of a pet’s life may actually be more crucial for clients than in the middle, and I think that’s why we receive most gifts and cards after euthanasias. We rarely get them after a difficult diagnosis followed by a successful treatment plan, right?

Whether or not it makes sense, clients need to know that you are on their side at the end, and that includes being straight with them. You don’t need to lie and say that Fluffy has cancer, if you’re unsure. Instead, you can say, “I am really worried that this is cancer, and not the treatable kind. I cannot be sure right now, but if I were to take a nonscientific guess, I would say that there is a 90 (or any number) percent chance that this is a terminal cancer. I do not know how long she has, but it could be as little as 2 weeks.” This part is important. People do not know that cancer progresses faster in cats and dogs than in humans, and we tend to catch it at an already advanced state. You can add, “We can send you to a specialist and have a biopsy done to find out. Are you interested in that?” Then, you can estimate the cost and possible risks if you know.

It is also acceptable to say that you think it is a untreatable disease and that doing further testing might not help with treatment. You are allowed to say what you think, as long as you offer a workup to confirm or refute your suspicions. You are also allowed to guess at how long the patient might have, as long as you say it is a guess. Sometimes I will say “days rather than weeks,” “weeks rather than months,” or “months rather than years.”

If you use the informative approach, what the client hears is that there is a list of equally likely possibilities, that we don’t have any idea what disease the pet has, and that there is hope that “whatever it is” is totally curable or most likely easily fixable.

We might think that the clients cannot handle it. Believe me, they can. I am tearfully thanked by pet parents many times a day for “giving it to them straight” or “not sugar-coating it.” The bond between doctor and client does not have to break at the end of a pet’s life or period of good health, or in the face of mistakes, accidents, grief, or anxiety. With just a conversation and an open line of communication, we can make a difference for clients, even in situations in which we can no longer make a difference for the patient. What if it just takes a conversation?

Read more about this topic in Englar’s book, A Guide to Oral Communication in Veterinary Medicine or her textbook, Common Clinical Presentations in Dogs and Cats.

Ryane Englar, DVM, DABVP (Canine and Feline Practice), is founding faculty, associate professor, and director of Veterinary Skills Development at the University of Arizona College of Veterinary Medicine where she designs and implements the Professional and Clinical Skills curriculum for 1st and 2nd year veterinary students. As the sole author of various books and a proponent of teaching interpersonal skills in the veterinary curriculum, she has developed a state-of-the-art, simulation-based communication curriculum for the University of Arizona and continues to research client communication to facilitate the training of students in interpersonal skills around the globe.

References

1. Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300(14):1665-1673. doi:10.1001/jama.300.14.1665
2. Gawande A. Being Mortal: Medicine and What Matters in the End. MacMillan, 2014. https://highlights.sawyerh.com/highlights/Pn9aQTB3VbDfh2SB7jG6
3. Emanuel EJ and Emanuel LL. Four models of the physician-patient relationship. JAMA.1992;267(16):2221-2226. doi:10.1001/jama.1992.03480160079038