Back to the Basics: Breaking Bad News, Cancer Findings in the ED

Christine Collins, MD

Your patient presents to the ED with flank pain and history of anemia. You obtain a CT scan and find a large kidney mass, with evidence of mets to the pelvis, liver, and multiple metastasis to the lungs. They have no known history of cancer. What do you tell the patient? How do you deliver bad news when you have no established relationship with the patient, there is no foundation of trust and there is limited information available? 

Unfortunately initial cancer findings from ED visits often have a worse prognosis due to the delay in diagnosis. Some studies have shown that approximately 10% of cancer diagnosis are made based on findings from the ED. Those with lower socioeconomic status and the elderly are more likely to have an emergency diagnosis of cancer rather than cancer diagnosed by their primary care doctor during routine screening.  

When evidence of cancer is found in the ED, it is crucial that the patient be made aware of findings with a stress on follow up. This can be challenging, especially when there is uncertainty about a patient’s diagnosis and prognosis. Patients will understandably have questions that will not be able to be answered in the emergent setting. Physicians must recognize their limitations, and work to deliver straightforward and empathetic disclosures of evidence of cancer.

Below are some tips in approaching these discussions with patients:

• Prepare before you enter the room. You can use “SPIKES” protocol to help organize yourself in advance**
• Run your list of current active patients you are seeing in the ED  to ensure you aren’t going to be disrupted. Update nursing staff when you are going into the room in advance to minimize interruptions. Leave your phone behind unless you plan to use it during the communication.
• Offer to have family members be a part of the discussion. In COVID times, this may need to be over the phone. Listen to and follow the patient’s wishes for dissemination of knowledge.
• Stress diagnostic uncertainty. Be honest about the limitations of your knowledge. Some good phrases could be: “Today we found some abnormalities on your CT - we are concerned that this could be cancer and it is very important that you follow up closely. For now, I am here to listen and support you.”
• Assess and respond to patient’s emotional responses. Be present and listen.  Sit.  Create space for the patient’s response.  
• Create a system for your patient to not be lost to follow up. Assist the patient in making a follow up appointment with an oncologist. Communicate with the patient’s primary care physician the results. Follow up in a few days - make sure that the patient was set up with appropriate follow up.  

**SPIKES Protocol for delivering bad news 

Set the scene. create privacy

Perception. Ask the patient about their perception. Use open-ended questions.

Invitation. Ask the patient how they want to hear the news.

Knowledge sharing. Use non-technical terms. Be straightforward

Emotions. Respond to patient’s emotions.

Strategy and summary. Summarize discussion. Assess patient’s understanding. 

References:

1. VandeKieft GK. Breaking bad news. Am Fam Physician. 2001;64(12):1975-1978.
2. Black G, Sheringham J, Spencer-Hughes V, et al. Patients' Experiences of Cancer Diagnosis as a Result of an Emergency Presentation: A Qualitative Study. PLoS One. 2015;10(8):e0135027. Published 2015 Aug 7. doi:10.1371/journal.pone.0135027
3. Swenson KK, Rose MA, Ritz L, Murray CL, Adlis SA. Recognition and evaluation of oncology-related symptoms in the emergency department. Ann Emerg Med. 1995;26(1):12-17. doi:10.1016/s0196-0644(95)70231-8
4. Gary A Abel, Silvia C Mendonca, Sean McPhail, Yin Zhou, Lucy Elliss-Brookes and Georgios Lyratzopoulos British Journal of General Practice 2017; 67 (659): e377-e387. DOI: https://doi.org/10.3399/bjgp17X690869