Breaking Bad News and Discussing Code Status: Why and How

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Introduction

Truth-telling and breaking bad news to patients is one of the most difficult responsibilities in the practice of medicine. Although virtually all physicians in clinical

practice encounter situations entailing bad news, medicalschool offers little formal training in how to discuss badnews with patients and their families. Although themajority of health providers believe that patients andcaregivers should be told the truth about the prognosis,in practice, many either avoid discussing the topic or withhold information. However, avoiding the topic canhave adverse outcomes, such as patients receiving

burdensome and painful treatments and not havingsufficient time to prepare for death. Unfortunately, thisfrequently happens as is clearly illustrated in thefollowing account written by an oncologist (Rockwell,2007):

―Tears rolled down his cheeks as he stood motionless outsidehis dying son’s door. He seemed to be standing vigil. We

shook hands. Our eyes met. The lines of his face were etched with grief. I waited for him to speak."No one told us..." "I’m sorry?" I asked. "No one told us Jack was dying," he replied. His tears

streamed.

His words poured over me. The door of his sadnessopened, and I plunged into his shock and apparent betrayal.

In that moment I felt ashamed of being part of the system that had betrayed him, his son, and his family. In our silence, I imagined the countless opportunities that had been abandoned by his doctors, hurriedly dismissed, as another priorityconveniently emerged, and a too time-consuming, too-intimateconversation was, again, postponed.

At 26, Jack was diagnosed with myelodysplastic syndrome. All the wrong cytogenetics lined up neatly,

declaring the road to come. Induction chemotherapy was followed by consolidation. He was young, strong, vibrant, and beautiful. He was only 26. He fared well... for a year.

Then Jack developed a bluish patchy rash that persisted for weeks. A biopsy revealed leukemia cutis. Hismyelodysplastic syndrome had transformed into acuteleukemia, and the revolving door was re-entered. Reinduction.Consolidation. Plans for allogeneic transplantation weremade. When Jack and his sister learned she was a match — he,

perched atop an examining table, and she, folded into a tight ball on a nearby chair — they practically leapt into eachother’s arms, tears streaming down their faces as they held each other in a long and laughing embrace. His baby sister beamed with pride that she alone held the key to her brother’scure.

The roller coaster of admissions and dischargesbegan. The track was long and circuitous. Predictablyunpredictable. Neutropenic fever. Line infection. Sepsis. Twice,

Jack survived admission to the intensive care unit. He was young and strong. Quietly, his vibrancy began to recede.

Communicating the Bad News and Discussing Code Status:Why and How

Maria Fidelis C. Manalo, MD, MSc.

Department of Community and Family Medicine

Truth- telling and “breaking the bad news” to patients and their families is one of a physician’s most challenging jobs, yet medical education typically offers little formal training for this arduous task. This is especially so asthe attitudes and practice of the physicians towards truth-telling are affected by the cultural and ethical norms,and the social milieu where the physicians and their patients live. Without proper training, the discomfort anduncertainty associated with breaking bad news may lead physicians to emotionally disengage from patients.Numerous study results show that patients generally desire frank and empathetic disclosure of a terminaldiagnosis or other bad news. Focused training in communication skills and techniques to facilitate breakingbad news has been demonstrated to improve patient satisfaction and physician comfort. Physicians can usethe SPIKES strategy both in breaking the bad news or discussing code status.

Key words : code status, SPIKES strategy

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On his good days, his olive-green eyes shone like jewels. Hisbalding head accentuated his handsome face. He didn’t seemto mind his change in appearance. He was patient and kind,often serving as a reminder to all of us who cared for him of our own inadequacies. On his bad days, he was profoundly

fatigued, unable to stroll down the fluorescent corridors or tocome to the table and eat with family during his brief stints at home. This energyless state was foreign to Jack. He had beenan "extreme" biker and mountain climber. He felt estranged

from this alien self, who only knew how to lie in bed and watch mindless television.

During these days, his father drew closer to his side. In a weathered, leather bag that rested beneath Jack’s bed, his father kept healing oils. He would lovingly massage his son’s frail body, as if to breathe life into every cell through the strength and love in his hands. Jack’s father was his soul mate,his champion. His dad donned various colorful bandanas fromone day to the next to match his son’s. He shaved his head asa gesture of solidarity with Jack. He, too, was kind and patient,holding vigil for his son. With gentle determination, he would inquire regarding the day’s events— the scans, blood cultures,chest x-rays, and so on. He was witness to the rise and fall of

fevers and blood counts. As his son rode the roller coaster that was now his life, with little or no control, his father was

steadfast. It was amazing to watch. We all admired hisendurance. It fed us — this loving, unhindered display of commitment. We were grateful for their strength and kindnesstoward one another.

After the transplantation, his remission lasted 3months.

Reinduction. Not a word of death or dying was offered by the doctors caring for him, though the chance of cure wasnil. No mention of hospice. As an oncology fellow, I stood more or less in the wings, disheartened by the absence of dialogue, reluctant to speak my own peripheral truth. What

was I witnessing? His frailty grew. His exhaustion deepened as his body was assaulted with each round of chemotherapy. Discussion of goals grew more elusive. It was as though anunseen pilot was steering this relentless course. Was it hope?Whose hope? Who defines this hope?

This time there was no remission. At what price is cure a goal? And what price does hope

carry? More trips to the intensive care unit and more bouts of sepsis. His young body was now a relic. There was talk of another transplant... anothe r chance....‖

Indeed, healthcare professionals often censor their information giving to patients in an attempt to

protect them from potentially hurtful, depressing, or socalled ―bad news‖. There is a commonly expressed

belief that what people do not know does not harm them.Analysis of doctor and nurse/patient interactions revealsthat this well-intentioned but misguided assumptionabout human behavior is present at all stages of cancer care. Less than honest disclosure is seen from themoment that a patient reports symptoms, to theconfirmation of diagnosis, during discussions about the

therapeutic benefits of treatment, at relapse and terminalillness. This desire to shield patients from the reality of their situation usually creates even greater difficulties for

patients, their relatives and friends and other members of the healthcare team. Although the motivation behindeconomy with the truth is often well meant, a conspiracyof silence usually results in a heightened state of fear,anxiety and confusion, rather than one of calm andequanimity. Ambiguous or deliberately misleadinginformation may afford short-term benefits while thingscontinue to go well, but denies patients and their familyopportunities to reorganize and adapt their lives towardsthe attainment of more achievable goals, realistic hopes,and aspirations (Fallowfield et al, 2002), and eventuallyto prepare for death.

Patient’s Right to the Truth

Man, though not owner is steward of his life andhealth. To hide the truth from a patient is tounderestimate his capacity and to treat him as immature.It is not licit to create illusions which lead to a falsesense of security in the patient or his family, thereby,endangering his eternal salvation or impeding him fromfulfilling his obligation of justice or charity.‖ There arecases wherein the physician is obliged to talk clearly, aduty which takes priority over any other medical or humane consideration. It would be erroneous to justifysuch conduct or explain it by saying that the physiciancommunicates the truth in the manner that best suits the

patient. (Monge, 1994)

Health Care Professionals Must Not Lie

―To lie‖ is to say something contrary to whatone thinks. A health care professional should never lie or deceive the patient. One is not always obliged to tell thewhole truth if one judges that revelation could have anegative effect upon the patient. Sometimes, the

physician may keep silent about the truth, evadinganswers to indirect questions by the patient made for other motives (to get reaffirmed, to revive hope, toovercome fear, etc.). He waits for the opportune momentto reveal the truth. Better still, he tries to reveal itgradually. (Monge, 1994)

H ealth Professionals’ Dilemma: What if theTruth Hurts?

The principle which is universally valid is: ―The patient has the right to know the truth about his illness.‖An exception to this norm would be patients of minor age (small children who do not have full use of their mental faculties). The physician will have to inform their

parents or legal guardians. (Monge, 1994).

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Many health professionals (HPs) expressdiscomfort at having to broach the topic of prognosis,including limited life expectancy, and may withholdinformation or not disclose prognosis. A systematicreview (Hancock et al, 2007) was conducted of 46studies relating to truth-telling in discussing prognosiswith patients with progressive, advanced life-limitingillnesses and their caregivers. Inclusion criteria werestudies of any design evaluating communication of

prognostic information that included adult patients withan advanced, life-limiting illness; their caregivers; andqualified HPs. Results showed that although the majorityof HPs believed that patients and caregivers should betold the truth about the prognosis, in practice, manyeither avoid discussing the topic or withhold information.Reasons include perceived lack of training, stress, notime to attend to the patient’s emotional needs, fear of anegative impact on the patient, uncertainty about

prognostication, requests from family members towithhold information and a feeling of inadequacy or hopelessness regarding the unavailability of further curative treatment. However, the studies reviewedsuggest that patients can discuss the topic withoutnecessarily increasing anxiety. Furthermore, avoidingthe topic can have adverse outcomes, such as patientsreceiving burdensome and painful treatments and nothaving sufficient time to prepare for death. Bydiscussing this information sensitively, and encouragingthe patient to share in decision-making, the HP can helpthe patient reset goals and choose appropriate supportivetreatments rather than those that are burdensome.

May the common clinical conversation be usedto explore whether or not seriously ill patients want totalk about possible limitations of life support? In a study

by Löfmark and Nilstuna (2000), a clinical conversationwith 20 seriously ill patients was used to identifydifferent reaction patterns among typical DNR patients.Within 10 – 20 minutes of conversation, most patientsseemed to be ready to talk about fundamental questionsof life and death. It was also quite easy to get an idea of

both the patient’s values and his or her understanding of medical issues. For example, their knowledge aboutCPR was often very poor. Many patients approved. Theyalso emphasized that it is the doctors’ duty to give suchinformation to their patients. After talking about their diagnosis and prognosis, most patients said it wasnatural to talk about possible limitations of life support,and a substantial number immediately indicated that theydid not want any life-sustaining treatment. Althoughtheir emotional reactions were different, no one seemedto be troubled or upset by talking about such issues.Many but not all patients said that they wanted a familymember and possibly also a nurse to participate in theconversation.

Truth-Telling: the Philippine Cultural Dimension

A paternalistic attitude toward truth telling inmedicine is dominant in the Philippines. Influenced byAsian philosophies and cultures, the tradition of Filipinovalues and ethics emphasizes the good behavior of the

practicing physician rather than a system of principlesand rules.

The Filipinos feel that disclosure of bad news brings loss of hope and unwanted emotional distresswhich may lead to isolation, depression, and in theelderly, even a possible angina, heart attack, and earlier demise.

In the Philippines, families want to hear thenews first. They care for their sick at home, rather thanin institutions. Family bonds are so strong in thePhilippines that they would rather bear the psychologicalshock of the bad news of a terminal diagnosis rather thanshare it with their loved one. They want their dear familymember to remain hopeful and optimistic. And for their

part, especially among the elderly, patients prefer not to be informed of a terminal illness. They willinglyrelinquish their right to autonomy and let familymembers make health care decisions for them.

As in the rest of Philippine society, there arestrong authoritarian and paternalistic elements in thePhilippine healthcare system. In typical Filipino tradition,a good physician is paternalistic. Accordingly, he wouldnot disclose to a patient that he has terminal disease suchas cancer; rather he would tell the spouse, the children,the siblings, or other close family member. For example,even when there is already a suspicion of a malignancy,

physicians often do not fully explain to the patient thereason for a planned examination and don’t disclose testresults directly to them. Sometimes chemotherapeuticdrugs are prescribed or administered without directlyinforming the patient that they are a form of cancer treatment. Preferring thus not to inform cancer patientsof the nature, course, and prognosis of their conditioneven at stage 4, advance directive discussions are rare.

However, little by little, the attitude of younger physicians towards truth telling suggests a transitionfrom the long tradition of paternalism to a modernembrace of the principle of patient autonomy. This is soamong those with training on effective communicationskills during medical school or during residency trainingin family medicine in university hospitals especially inMetro Manila. Likewise this is prevalent among thoseexposed to contemporary Anglo-American concept of autonomy. US trained doctors assert the rights of

patients to be informed of their diagnosis, prognosis andthe risks and benefits of therapies, and to be allowed tomake informed decisions about treatments andwithholding resuscitation.

8 Communicating the Bad News and Discussing Code Status



The Truth Need Not Hurt

In the first place, it has not been demonstratedthat truth-telling harms the patient. Telling the truth isoften beneficial and alleviating if done properly. Just as

a physician does not hesitate to cause physical painwhen he prescribes a painful or mutilating treatment, inthe same way, he must not be held back for fear of causing moral suffering when he has to communicateinformation because the truth is often beneficial (both

physically and spiritually). What influences more thanthe content of the information is the manner of communicating it. This depends primarily upon the

patient-physician relationship. The key to the problem isgood communication. (Monge, 1994)

It is better to inform gradually, always leavingsome hope, but never telling a lie. The purpose of the

universally accepted norm of informing the patient properly is to enable him to adapt to the differenttherapeutic maneuvers without alarming himunnecessarily. This principle obliges the physicianalways to explain the gravity and prognosis of the illness.He is not bound to give percentages, mean survival,frequency of complications, etc. This can be done whenone knows the personality of every patient. He must begiven the dose of information that he needs at everymoment without stating survival time and maintaining a

prudent reserve as regards unforeseen events. (Monge,1994)

Practical Guidelines on Telling the Truth toDifferent Patients

Terminally-ill patients usually suspect that their condition is grave and that they are in the final phase of life because of their poor general condition, kind of therapy, etc. Thus, it is enough to confirm gradually their impression. Nevertheless, one must always give hope.The knowledge of their illness need not cause despair.

Terminally-ill patients fall into despair onlywhen the truth is revealed to them in a brutal way and

they are thereafter abandoned. The medical team mustsupport them by not only giving them the impressionthat it will never cease to take care of them; it mustreally do so. For example, patients can be givensymptomatic relief for fever, appetite stimulants,analgesics and help them receive their families, etc.

For terminally-ill patients who really or apparently ignore their actual state, it is an urgentobligation on the part of the physician to inform the

patients themselves adequately. In difficult cases,sometimes a close relative (wife, husband, children or afriend) might be in a better position to communicate it.The suffering that results from this gesture is justified bythe fulfillment of a final duty. Man needs to beforewarned of the moment of his death so that he can

prepare himself with a lucid mind. He may need or wantto settle matters with others, fulfill moral, familial, and

personal obligations which cannot be delegated.For a seriously-ill and incurable patient but with

a certain chance of survival (e.g., primary stage of cancer), the patient should be gradually informed aboutfacts related to his illness. The physician, with thenurse’s assistance, will judge whether it is advisable toinform the patient immediately or to defer it until a moreopportune moment. In this regard, the interest of the

patient (personal, professional, familial and religious)should be taken into consideration. (Monge, 1994)

Preferences of Cancer Patients RegardingCommunication of Bad News

The findings in the systematic review of 24studies made by Fujimori and Uchitomi (2009) suggestthat patient preferences with regard to thecommunication of bad news by physicians consist of four components: setting, manner of communicating badnews, what and how much information is provided andemotional support, and that patients’ preferences areassociated with demographic factors. Younger patients,female patients and more highly educated patientsconsistently expressed a desire to receive as muchdetailed information as possible and to receive emotionalsupport. Asian patients were shown to prefer thatrelatives be present when receiving bad news more thanWesterners do and to prefer to discuss their lifeexpectancy less than Westerners.

Breaking Bad News: The ABCDE Mnemonic

Physicians can build on the following simplemnemonic, ABCDE, to provide hope and healing to

patients receiving bad news: Advance preparation —arrange adequate time and privacy, confirm medicalfacts, review relevant clinical data, and emotionally

prepare for the encounter. Building a therapeuticrelationship — identify patient preferences regarding thedisclosure of bad news. C ommunicating well —determine the patien t’s knowledge and understanding of the situation, proceed at the patient’s pace, avoidmedical jargon or euphemisms, allow for silence andtears, and answer questions. Dealing with patient andfamily reactions — assess and respond to emotional

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Step 2: Identify the cause or source of the emotion,which is most likely to be the bad news that the patienthas just heard.

Step 3: Show the patient that you have made theconnection between the above two steps — that is, thatyou have identified the emotion and its origin. Examplesmight include:

―Hearing the resu lt of the bone scan is clearly amajor shock to you.‖ ―Obviously, this piece of news is veryupsetting.‖ ―Clearly, this is very distressing.‖

Once you have shown empathy and identifiedand acknowl edged the patient’s emotion, be ready tovalidate or normalize his or her feelings. You might usea phrase such as ―I can understand how you can feel that way.‖ To minimize feelings of embarrassment andisolation, let your patient know that showing emotion is

perfectly normal..

Strategy and summary (S)

Before the discussion ends, summarize theinformation in your discussion and give your patient anopportunity to voice any major concerns or questions. If you do not have time to answer them right at thatmoment, you can tell your patient that these issues can

be discussed in detail during your next interview. Youand your patient should go away from the interview witha clear plan of the next steps that need to be taken andthe roles you both will play in taking those steps.

Discussing Code Status: The S-P-I-K-E-S Strategy

Conversations about cardiopulmonaryresuscitation (CPR) preferences vary greatly dependingon the age, health and health literacy of the patient. Withall patients it is important to avoid vague or overlytechnical terminology and to use vocabulary theyunderstand. The question ―Would you want us to doeverything?‖ is not helpful for eliciting preferences; itconfuses patients and implies that less than optimal caremay b e offered if the patient answers ―no‖ to thequestion. CPR should not always be the standard of care, so it is crucial that patients understand thedifference between withholding CPR and withholdingtreatment of their underlying illness and its associatedsymptoms. (Stone and Tulsky, 2006)

Steps in discussing prognosis and end-of-lifeissues have been proposed by Von Gunten andWeissman (2005). Adapting the S-P-I-K-E-S protocol as

previously described to this process of discussing code

status to patients and families is a simple, easily learnedstrategy.

Setting (S)

Ensure comfort and privacy; sit down next to the patient. Ask if family members or others should be present. Introduce the subject with a phrase such as: ―I’like to talk with you about possible health care decisionsin the future.‖

Perception (P)

An informed decision about code status is only possible if the patient has a clear understanding of their illness and prognosis. Ask an open-ended question toelicit patient understanding about their current healthsituation. It is important to get the patient talking – if thedoctor is doing all the talking, it is unlikely that the restof the conversation will go well. Start with phrases suchas: ―What do you understand about your current health

situation?‖ ―What have the doctors told you about your condition?‖ If the patient does not know/appreciate their current status this is time to review that information.

Invitation (I)

Find out what the patient expects. Ask the patientto consider the future. For example:

―What do you expect in the future?‖

―What goals do you have for the time you haveleft —what is important to you?‖

This step allows you to listen while the patientdescribes a real or imagined future. Many patients withadvanced disease use this opening to voice their thoughtsabout dying — typically mentioning comfort, family, andhome, as their goals of care. If there is a sharpdiscontinuity between what you expect and what the

patient expects, this is the time to clarify.Listen carefully to the patient’s responses; most

patients have thought a lot about dying, and only need permission to talk about what they have been thinking.

Respond with clarifying and confirmingcomments such as:

―So what you’re saying is – you want to be ascomfortable as possible when the time comes?‖―What you’ve said is – you want us to doeverything we can to fight, but when the timecomes, you want to die peacefully?‖

Whenever possible, ask patients to explain thevalues that underlie their decisions:

―Can you explain why you feel that way?‖

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Knowledge (K)

Share the Information. Discuss a Do notResuscitate (DNR) order. Use language that the patientwill understand. Give information in small pieces. Don’tintroduce cardiopulmonary (CPR) in mechanistic terms

(e.g. ―starting the heart‖ or ―putting on a breathi ngmachine‖). Never say: ―Do you want us to doeverything?‖ ―Everything‖ is euphemistic and easilymisinterpreted. Using the word ―die‖ helps to clarify thatCPR is a treatment that tries to reverse death. To mostlay-people, when the heart and/or lungs stop, the patientdies.

If the patient and doctor mutually recognize thatdeath is approaching and the goals of care are comfort,then CPR is not an appropriate medical intervention anda clear recommendation against CPR should be made.

You can say : ―Wehave agreed that the goals of care are to keep you comfortable and get you home.With this in mind, I do not recommend the use of artificial or heroic means to keep you alive. If you agreewith this, I will write an order in the chart that if you

suffer a cardiopulmonary arrest, no attempt toresuscitate you will be made.‖

If the clinical situation is more ambiguous interms of prognosis and goals of care, and you have noclear recommendation, the issue of DNR can be raised

by asking:―If you should su ffer a cardiopulmonary arrest in spiteof all of our efforts, do you want us to use heroicmeasures to attempt to bring you back?‖―How do you want things to be when you suffer acardiopulmonary arrest?‖

If you are asked to explain ―heroic measures‖,then describe the purpose, risks and benefits of CPR ingreater detail. The clinical pearl here is to start generaland become specific later in the conversation.

Empathize (E)

Respond to emotions. Strong emotions arecommon when discussing death. Typically theemotional response is brief. The most profound initialresponse a physician can make may be silence,

providing a reassuring touch, and offering facial tissues

Strategy and summary (S)

Establish a plan. Clarify the orders and plansthat will accomplish the overall goals you havediscussed, not just the DNR order. A DNR order doesnot address any aspect of care other than preventing theuse of CPR. It is unwise and poor practice to use DNR status as a proxy for other life-sustaining therapies.

Consider using words:―We will continue maximal medical therapy to meet

your goals. However, if you suffer from acardiorespiratory arrest, we won’t use CPR to bring youback.‖―It sounds like we should move to a plan that maximizes

your comfort. Therefore, in addition to a DNR order, I’d like to talk further with you how we can best do that.‖

The S-P-I-K-E-S protocol applied to disclosureand advance directives discussions provides a simple,easily learned strategy for physicians to effectively andmeaningfully communicate with their patients . ( Table 1)

Table 1. S-P-I-K-E-S Strategy in Breaking the Bad News and Discussing Code StatusDISCLOSURE

(BREAKING THE BAD NEWS)ADVANCE DIRECTIVES

(DISCUSSING CODE STATUS)S – Setting o Privacy

o Involve significant otherso Sit downo Look attentive and calmo Listening mode: silence and repetitiono Availability

o Privacyo Involve significant otherso Sit downo Look attentive and calmo Listening mode: silence and repetitiono Availabilityo Introduce the subject:

―I’d like to talk with you about possiblehealth care decisions in the future.‖

P – Perception Find out how much the patient knows.o ―What did you think was going on with you

when you felt the lump?‖o ―What have you been told about all this so

far?‖o ―Are you worried that this might be something

serious? ‖‖

Find out how much the patient knows.o ―What do you understand about your current

health situation?‖o ―What have the doctors told you about your

condition?‖

Communicating the Bad News and Discussing Code Status12



I – Invitation Find out how much the patient wants to know.o ―Are you the kind of person who prefers to

know all the details about what is going on?‖o ―How much information would you like me to

give you about your diagnosis and treatment?‖

o ―Would you like me to give you details of what is going on or would you prefer that I

just tell you about treatments I am proposing?‖

Find out what the patient expectso ―What do you expect in the future? ‖ o ―What goals do you have for the time you

have left — what is important to you? ‖ o ―So what you’re saying is – you want to be as

comfortable as possible when the timecomes?‖

o ―What you’ve said is – you want us to doeverything we can to fight, but when the timecomes, you want to die peacefully? ‖

o ―Can you explain why you feel that way? ‖ K – Knowledge Share the information.

Give warning statements:o ―Unfortunately, I’ve got some bad news to tell

you.‖ o ―I’m so sorry to have to tell you….‖

Check perception:o ―Do you see what I mean?‖o ―Is this making sense so far?‖

Share the information. Discuss a CPR or DNR order. Give warning statements:

o ―We have agreed that the goals of care are tokeep you comfortable and get you home.

However, if you should suffer a cardio-respiratory arrest in spite of all of our efforts,do you want us to use heroic measures toattempt to bri ng you back?‖

o ―How do you want things to be when you suffer a cardio- respiratory arrest?‖

If you are asked to explain ―heroic measures‖, thendescribe the purpose, risks and benefits of CPR or DNR in greater detail. Check perception.

o ―With this in mind, I do not recommend theuse of artificial or heroic means to keep youalive. If you agree with this, I will write anorder in the chart that if you suffer fromcardio-respiratory arrest, no attempt toresuscitate you will be made.‖

E – Empathy Ask probing questions:o ―How does that make you feel?‖o ―What do you make of what I’ve just told

you?‖ Respond to emotions. Identify the emotion and its

origin.o ―Hearing the result of the bone scan is clearly

a major shock to you.‖ o ―Obviously, this piece of news is very

upsetting.‖ o ―Clearly, this is very distressing.‖

Validate or normalize feelings:o ―I can understand how you can feel that

way.‖

Respond to emotions. Identify the emotion and itsorigin.

The most profound initial response a physician canmake may be silence, providing a reassuring touch, and

offering facial tissues

S – Strategy &summary

Summarize the information.Give the patient an opportunity to voice any major concerns or questions.

Plan the next steps that need to be taken and the rolesthe doctor and the patient will play in taking thosesteps.

Summarize the information.Give the patient an opportunity to voice any major concerns or questions.

Clarify the orders and plans that will accomplish theoverall goals discussed, not just the CPR or DNR order:

o ―We will continue maximal medical therapy tomeet your goals. However, if you suffer acardiorespiratory arrest, we won’t use CPRto bring you back.‖

o ―It sounds like we should move to a plan that maximizes your comfort. Therefore, inaddition to a DNR order, I’d like to talk

further with you how we can best do that.‖

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Medical Team as a Support to the Patient at theend-of-Life

The presence of the physician is especiallyneeded during the terminal phase, e.g., twice-a-day visits

to the dying patient. The physician ought to accompanythe patient, comfort the relatives, help them confront theillness and understand the meaning of suffering. This isnot the exclusive task of the chaplain, the spiritualcounselor or the palliative care practitioner. If the patientis a Christian, the physician may teach his patients thatillness is not something ―accidental.‖ It is foreseen byGod for each individual. He should emphasize the needfor spiritual help (pastoral visit, sacraments of penanceand Holy Communion, anointing of the sick) in order toconfront the situation. (Monge 1994).

Conclusion

Despite the challenges involved in communicating badnews and discussing code status, physicians can findtremendous gratification in providing a therapeutic

presence during a patient’s time of greatest need. Agrowing body of evidence demonstrates that physicians’attitude and communication skills play a crucial role inhow well patients cope with bad news and that patientsand physicians will benefit if physicians are better trained for this arduous task. Patients cannot always becured and the goals of care would shift towards

palliation and comfort measures only. These are precisely the times that professionalism and compassionmost acutely call the physician to provide hope, and toaccompany the patient, to comfort the relatives, and tohelp them face the illness until the terminal phase, withempathy and real concern for them.

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Breaking Bad News and Discussing Code Status: Why and How