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Kolling Building Level 7

Royal North Shore Hospital


St Leonards. NSW 2065
Tel. +612 9926 4691

Sydney Medical School


A GUIDE TO FOUR EMOTIONS – DEALING WITH BAD NEWS

In the Dealing with Bad News (DBN) sessions last year, you were asked to take a history from a
patient who had recently been given a diagnosis of lymphoma. Your task was to park the history
and to attempt to address the patient’s emotional needs. This article provides a summary of
how to recognise and address four emotions.

In all cases be alert to the benefits of practical help:

A cup of tea | Tissues | Help with getting information | Facilitating a phone call (family, doctor)
| Comfort (arranging pillows etc.)

1. ANXIOUS PATIENT

How would you recognise an anxious patient?

The anxious patient is agitated, distracted and jittery and incapable of focusing their attention.
They display nervous gestures and signs of physical tension; their speech is rapid and fragmented
and their voice is tense and pitched higher than normal. Their posture is defensive.

What lies behind this presentation? What does it feel like to be anxious? The world feels out of
control and chaotic. Problems appear insoluble. Nobody is in charge and you have no
understanding and no plan.

The patient will attempt to regain a sense of control by collecting information, by consistently
asking questions and seeking some sort of understanding and control.

Possible strategies
 Address the anxiety and acknowledge the underlying concerns. This is called
‘normalisation’, simply letting the patient know that, given their situation, their anxiety is
a quite normal response.
For example: “This must be a trying time,”
“So much is happening so fast it must be difficult to take it all in.”
 Tell the patient that they will have time to make the relevant decisions and that no one
will pressure them for a decision before they are ready.
 Offer to sit with them and help generate some sense of structure around their questions.

University of Sydney Northern Clinical School


Kolling Building Level 7
Royal North Shore Hospital
St Leonards. NSW 2065
Tel. +612 9926 4691

2. ANGRY PATIENT

How would you recognise an angry patient?

The angry patient is agitated and hostile. Their behavior may range from irritability and
grumpiness, through withdrawing and refusing to interact, to shouting, using threatening
language or throwing things.

Compared with anxiety, anger is a relatively short-lived emotion and commonly passes like a
thunderstorm. Apart from rare cases of chronic anger, patients always have reasons for being
angry and the reasons may include: lack of sleep, lack of information, disturbances and lack of
privacy, delay in diagnosis or treatment, feeling depersonalised or not heard.

It is difficult for a student not to be affected by the patient’s anger – to be intimidated and fearful
or to become angry in response. If you have not experienced anything like the patient’s
experience, be wary of saying things like “I understand how you feel”. This can be very
inflammatory. Whatever the external triggers for anger, underneath the patient will be reacting
fearfully to a sense of abandonment or injustice in the way they are been treated, to loss of
control and a breakdown in communication.

Possible strategies

 Listen carefully to the patient’s concerns and endorse their right to be angry. This is called
‘validation’, simply letting the patient know that, given their situation, their anger is a
quite normal response.
For example: “If I were in your shoes I’d be feeling the same way,”
“After all you’ve been through, no wonder you’re angry.”
 Offer assistance: “Is there anything I can do? Like see if someone knows when your doctor
will be here?” - and then do it without delay.
 Resist any temptation to (1) take the anger personally, (2) defend the medical profession
and system, or (3) criticise the doctor or the system.

University of Sydney Northern Clinical School


Kolling Building Level 7
Royal North Shore Hospital
St Leonards. NSW 2065
Tel. +612 9926 4691

3. DISTRESSED PATIENT

How would you recognise a distressed patient?

The distressed (sad) patient is silent, still and physically withdrawn. They struggle to comprehend
questions and to give answers. They are overwhelmed by their emotion and struggling to control
it. Or they may be crying silently or openly. It is important to remember that, in most cases, tears,
like anger, are relatively short- lived. If you allow a distressed patient time and space to talk
about their sadness and to explore the depths of their despair, they will usually discover their own
hopeful messages.

Students they may find themselves drawn into the patient’s sadness to the point where it
becomes overwhelming for the student as well. If you have not experienced anything like the
patient’s experience, be wary of saying things like “I understand how you feel”. This can be seen
as trivialising. The challenge is to dig deeper into the situation by recognising that tears from a
patient do not represent failure on the student’s part or something the student did wrong. Tears
usually mean that the student has made the patient feel safe enough to express the emotion.

Possible strategies

 Sit still, sit close and listen quietly. Touch the patient only if you feel comfortable to do so.
Do not be embarrassed if the patient is or becomes tearful.
 Resist the temptation to press the patient to talk or to try to fix things. By listening
carefully you validate the patient’s right to be unhappy.
 Ask simple open-ended questions and wait, no matter how long it takes, for the patient to
answer.
 Name the sadness and follow up on any mention of family members.
For example: “You seem very upset.” “What is your daughter’s/father’s name?” “Can you
tell me about them?”

University of Sydney Northern Clinical School


Kolling Building Level 7
Royal North Shore Hospital
St Leonards. NSW 2065
Tel. +612 9926 4691

4. PATIENT IN DISBELIEF

How would you recognise a patient in disbelief?

Disbelief is not the same as denial. Denial typically takes three forms:
(1) Denial of fact: “This is not my story; this is not happening to me.”
(2) Denial of impact: “This won't change me. I don’t feel anything.”
(3) Denial of implications: “Anyway, it’s not serious.”

Disbelief is different. It is the beginning of the slow process of acknowledging the truth of what is
happening, coming to terms with a new status, making sure that one is not overwhelmed.
Disbelief is characterised by attempts to disprove or discredit the reality of the news.
For example: “This can’t be right.” “Do you think they might have mixed up my results with
someone else’s?” “If it was really serious, someone would have been in to see me straight away?”

The patient is the only one who knows their own ability to cope at this moment with the new
course of events, and it is the patient who must decide the flow of information they can accept.
Undue pressure from outside may only be overwhelming. The temptation for the student may be
to encourage them to face the facts. However nothing in particular needs to be confronted here
unless the disbelief extends into denial that threatens cooperation with treatment, in which case
the student needs to tell the registrar.

Possible strategies

 Recognise disbelief as a normal and natural part of the process of dealing with bad news
and NORMALISE this process for the patient.
For example: “There really is a lot to take in, isn’t there?” “It all sounds very confusing for
you right now. Much of this will become clearer when you have a chance to talk o your
doctor.”
 Give the patient time to talk through their concerns and queries at their own pace.
 Take an objective history. The history will remind the patient of their increasing concern
and the validity of their decisions leading to being in the right place now to receive
treatment.

University of Sydney Northern Clinical School