Dealing With The Emotional Patient

While I was giving a workshop on charting efficiency, a physician asked about how to deal with a patient who has a difficult diagnosis. When she breaks bad news to a patient, it is upsetting to the patient. She herself feels upset too. She is so upset that she cannot finish that patient’s chart before seeing the next patient. She then carries that upsetting emotion to see the next patient. The physician understands that it is negatively affecting her efficiency and she wants to know what to do about it.

Delivering bad news is a usual part of clinical medicine, no matter what specialty you are in. What is the best approach to handle the situation?

As a physician, the first thing is to manage your own emotion before going into the patient’s room. It is important to have the emotional capacity to handle challenging emotions. If you are fatigued, stressed or overwhelmed, it is difficult for you to handle more unpleasant emotions. When you learn of a patient’s diagnosis, why is it upsetting to you? In other words, what are you thinking about that is causing you to feel sad, angry, frustrated or other unpleasant emotions? One of the most common thoughts is that the patient should not have that diagnosis, or the patient should not have progressed with their disease.  Of course you do not want the patient to have any diagnosis worse than what they have now. You are here to help patients and you do not want anything worse than what they started with. Realize that even though you do everything according to the standard recommendations, there is still no absolute guarantee of the outcome. Instead of arguing with the situation, accept it as is. It has happened and you cannot go back in time to change it.

Allow yourself to feel your feelings. Acknowledge them. You are angry because you think that the cancer should not have progressed. You are frustrated because you are doing your best and the outcome is not what you expected. You are upset because you do not want the patient to be upset.

Managing your emotion does not mean ignoring your feelings. It means that you realize and acknowledge what you are thinking that is causing those feelings. You allow your feelings to exist and you allow yourself to experience them. At the same time, you are getting yourself ready to move forward – to take care of your patient.

Make sure the patient’s room in set up in a way that you are facing the patient and their families. When you walk into the room, walk in with calm and kindness. You are not in a hurry – this does not mean you will be spending hours with that patient. Find out what the patient knows. That will be your starting point. Share the bad news with the patient in a manner that is honest and gentle. You discuss the facts with kindness while paying attention to all the unspoken cues. Pause and allow the patient to digest the information and feel their feelings. The most common emotion upon hearing bad news is fear. Address the patient’s fear. What is the most concerning thing?

Listen and acknowledge the patient’s fear and concerns. Discuss and advise the patient on them. Let the patient know that you understand their feelings and what you are going to do about the situation. Let yourself focus on helping the patient with their diagnosis while attending to their emotional well-being.

When you get out of the room, take the extra few minutes to finish that patient’s orders and note. Remind yourself that you are doing your best to help the patient, physically and emotionally. You control what you can control. Whatever you cannot control, you are dealing with it as it comes. However grim the situation may seem, there is always some hope. We just need to find the right focus.

Take a deep breath. Thank yourself for dealing with that emotionally challenging situation with kindness. Remind yourself that you are here to help. That patient encounter may be taking longer than you expected and that is okay. As much as you do not want any patient to be sick, it happens, out of our control. What we can do, though, is to handle the situation with your best medical judgment and kindness. When you are ready, shift your focus and see the next patient.