Difficult Conversations: How to give bad news, according to a palliative care doctor

Bob Arnold is practiced in the art of delivering bad news.

As the founder of UPMC’s Section of Palliative Care and Medical Ethics, the director of the Institute for Doctor-Patient Communication and a distinguished professor of medicine at Pitt, Arnold’s research focuses on teaching communication skills to clinicians. He’s also a founder of VitalTalk, a not-for-profit company designed to promote better relationships between clinicians and seriously ill patients and their families.

Arnold defines bad news as information that disrupts your sense of the future. While many of us, hopefully, will never have to deliver news of a terminal illness, the ever-evolving COVID-19 pandemic has brought plenty of disappointments, cancellations and postponements — opportunities to practice the skill of delivering bad news. 

Pittwire asked Arnold to share how he came to study doctor-patient communication and to give some tips for how to have hard conversations. 

How did you come to specialize in communication?

I’m someone who had poorly communicated, and I wanted to get better. Doctors excel at the science part of our professions, and we are great at talking to each other, yet many of us are lost when it comes to the psychological aspects of doing a good job.

My primary research interest is ethical issues in medicine, and it seemed that even if a doctor was clear about what the right thing to do for a patient was, it was still hard to have the conversation about the next steps.

I began learning better communication skills by watching people who I thought were doing a good job and by reading business books about negotiation skills. I learned that what makes a conversation difficult isn’t always facts; it has to do with how the recipient is observing themselves, what’s at stake and how they are responding emotionally. 

What do skilled communicators do when delivering bad news?

One of the things they're doing is sitting with other people's emotions and not trying to fix them. They stay open and curious about what comes up. They are flexible. If their first approach doesn’t work, they try a different tack.

The strong communicators I observed were also less emotionally knocked off balance when they received a negative response. They were transparent about what they were feeling and could re-focus the conversation and remain grounded.

What should we take into consideration before delivering bad news?

Like any high stakes undertaking, it takes practice. 

I start out asking myself: How can I clearly state the facts, and how are they likely to respond to our conversation?  What am I trying to accomplish? 

Remind yourself that if someone is having an emotional reaction to something you told them, they are responding to the news — you haven’t done something wrong. 

An excellent way to start a conversation is by foreshadowing what’s to come. You could say, “I need to talk to you about something difficult.” Let them be ready.

Also, be aware of your emotional reactions. Consider what’s at stake for you, too. Otherwise, you get in your way. Our emotional reactions can keep us from being successful. One thing that influences our emotional reactions is relationality. I am better at difficult conversations with my patients than with my family because there are higher emotional stakes with people you are close to.

Lastly, if the person you are speaking to has a negative reaction, don’t make it better for them. The fact that they are upset means they care. 

For example, if you break up with someone and they get upset, don’t change course and say, “Oh, maybe we’ll just take a break instead.” They are upset because they heard you right, and their vision for the future has been disrupted. If you react to their feelings and try and make it better, you are just going to have to break up with them again. 

We’ve faced a barrage of bad news in the last few years. How can we take care of ourselves when we feel overwhelmed? 

When caring for people who have serious illnesses, you see a lot of sadness and an immense amount of love and strength. I see amazing families caring for each other, and I see health care providers going above and beyond. The question is, can I focus on that as much as I focus on the sad parts?

It is always the case that there are many really horrible things going on in the world. And the question is, where are you going to put your energy, and what gives you meaning in your day?

I joke that when I’m having a really bad day, I walk across the pedestrian bridge from UPMC Presbyterian to UPMC Montefiore and look for people who are lost. They are so thankful and appreciative after I give them directions to their destination. I feel better because, for a moment, I did some good.

Of course, that doesn't mean I shouldn't work for larger social changes, but it does mean I can view a setback as an opportunity that gives me meaning and a chance to do the good I can in the world. 

— Nichole Faina