The Day One Talk
Authors: Jennifer W. Mack, Holcombe E. Grier
Journal: Journal of Clinical Oncology (2004)

For the family of a child with cancer, the time of diagnosis is a time of emotional anguish. The formal discussion about the diagnosis and intended treatment frequently comes after a period of uncertainty. During this period, families are often acutely aware that cancer is the likely diagnosis, but the type of cancer, expected treatment, and likely outcome are initially unclear even to the physician. In addition, the child must often go through a series of uncomfortable tests and procedures. When the pediatric oncologist finally discusses the diagnosis and treatment with the family, fear about the news to come, combined with uncertainty, has created an anxiety that is difficult for the family to endure. Because cancer in children is rare, few physicians will find themselves in the position we just described. But every physician will at times need to deliver bad news to patients, and the principles that apply to our specific scenario may be generalized to the care of other patients with serious illnesses. Previous reports have indicated that the initial communication of bad news can negatively [1-4] or positively [5] affect adjustment to the diagnosis. Recurrent themes in the literature include the need for a quiet and private physical setting [4-7], the importance of accurate information [3,4,8,9], the need for clear communication without either overly technical language or euphemisms [10], and the importance of letting the patient’s or family’s reaction guide the flow of conversation [5]. Families frequently note the physician’s own emotional response [10,11] as one helpful aspect of the conversation that allowed for a sense of connection with the physician. Beyond the impact of communication on coping and adjustment, the patients’ understanding of their prognosis affects their choices for therapy [12], underscoring the need for physicians to communicate information about the natural history of the disease effectively and honestly. Similarly, in studies using hypothetical scenarios, patients’ understanding of the burden of treatment and the likely outcome of treatment influenced their choices about therapies [13]. Yet even when the physician communicates with accuracy and compassion, the stress of receiving bad news may prevent a patient or family member from retaining information. For example, one third of parents of children with newly diagnosed cystic fibrosis felt they had understood and retained less than half of what their doctor told them [14]. These findings suggest that one essential aspect of delivering bad news is ensuring that the exchange of information among the patient, family, and physician will continue as the shock of the initial diagnosis fades. Despite the importance of communication to the daily life of a physician, standards for education in this area have only recently started to emerge for medical students, with fewer established standards in residency and fellowship training [15]. Nevertheless, medical students and attending physicians alike can benefit from training in this area [16,17]. Although others [6,9,18,19] have reported on their personal approaches to delivering bad news, few guidelines exist for pediatricians or offer guidance about communicating with whole families. Here, we offer one method of delivering bad news to parents of children with cancer in hopes that our approach may be helpful to others and From the Department of Pediatric Oncology, Dana-Farber Cancer Institute; the Division of Pediatric Hematology/ Oncology Children’s Hospital; and the Department of Pediatrics, Harvard Medical School, Boston, MA.