A Q&A with crisis communication expert Lisa Dinhofer, MA, CT
Q. As a counselor and communicator, you are expert and experienced in managing serious situational difficulties up to and including coping with sudden unexpected death. How would you think it best to approach a person with cancer who is being told, “your cancer has spread”?
A: I’ll answer this question by posing another—how did you discuss the diagnosis initially? Did you jointly establish expectations for addressing this illness going forward?
How a diagnosis is delivered plays a critical role in future conversations around how the illness is responding—or not—to treatment. This initial conversation is the foundation for many more that could go in various directions dependent on disease progression, regression, and patient tolerance.
It’s about process and setting the expectation that you are partnering with the patient in their care, which will include honest and compassionate discussion about options as they become available or diminish. How individuals view a diagnosis changes over time. What can’t be imagined initially may become preferred eventually. Leave room for the unknown.
Initial communication principles that include, “As we address this illness, as we see how your illness is responding, we can continue to make decisions based on what we’re seeing,” set a stage for gentle openers and segues if the need to relay unwanted news becomes necessary. Referencing the illness’s response versus the patient’s, “failure” to respond to treatment rests on the disease not the person.
Strive for balance between optimism, hope, and acknowledgement of the situation’s seriousness. Hope and honesty are not binary. Neither are pragmatism and sensitivity. When allowed, hope’s definition can change in meaning resonant with fluid situations.
A talented artist friend battling lung cancer that had spread to her brain remarked that “hope had become a leash” used by family to drag her from coping and conversing honestly in a way she so desperately needed and wanted in her remaining time. She became more prolific as her illness progressed, enough for a successful gallery show, and used her work to “break through” to her family. Her hope transformed from being cured to preparing her young daughter and husband for what lay ahead. We met in pottery class where she made the urn for her cremains.
The following phrasing suggestions incorporate points above with basics for giving bad news:
- “(Patient’s name), we need to discuss your latest test results. Honestly, they are disappointing.” (Pause). This is a “warning shot,” giving the patient an opportunity to psychologically “suit up.”
- “The tests reveal the illness has spread to ________. (Pause for a few beats to sink in. Rushing on increases the likelihood they won’t hear anything else.) I’m so sorry, (name.)” (This is an apology for their circumstances, not your failure).
- “What this means is _______________.”
- “Here are options for us to consider_____________.”
If a terminal condition, that does not mean there are no options; it means there are different options than before. The goals of your care might change from treatment to palliative, dependent on a patient’s perspective.
The most important principles for delivering difficult news are preparation, controlling beforehand any personal discomfort so as to completely focus on them rather than rushing to end the conversation, telling what you know when it is known to be true, and remembering that this is about them, not you.
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