Emotions in the room: Common emotional reactions to discussions of poor prognosis and tools to address them

Abstract

Introduction:

Advanced cancer patients often want prognostic information, and discussions of prognosis have been shown to enhance patient understanding of their illness. Such discussions can lead to high-quality, value-consistent care at the end of life, yet they are also often emotionally challenging. Despite how common and normal it is for patients to experience transient emotional distress when receiving “bad news” about prognosis, emotional responses have been under-addressed in existing literature on prognostic discussions.

Areas covered:

Drawing upon psychology research, principles of skilled clinical communication, and published approaches to discussions of serious illness, we summarize patients’ common emotional reactions and coping strategies. We then provide suggestions for how to respond to them in clinic.

Expert opinion:

Ultimately, effective management of emotional reactions to bad news may lead to earlier, more frequent, and more transparent discussions of prognosis, thus promoting cancer patients’ understanding of, and adjustment to, their illness and improving the quality of their end-of-life care.

1. Introduction

One of the many challenges that advanced cancer patients, their families, and clinicians face is the discussion of poor prognosis. Prognostic discussions are often desired by patients, can increase patient understanding of their cancer, and lead to high-quality, value-consistent care at the end of life [1–3]. Yet, given how emotionally-charged discussions of poor prognosis can be, they are among the most challenging situations in clinical oncology.

It is common and normal for patients to have emotional responses when receiving “bad news” about prognosis [4], because it represents a serious threat to their well-being and survival. Although prognostic discussions (e.g., about how long a patient with advanced cancer might live, and possibly, what that life might look like) have not been shown to increase syndromal depression or anxiety or disrupt the patient-physician alliance [5, 6], clinicians are understandably concerned about the emotional distress these discussions may evoke. Clinicians may find it difficult to navigate the delicate balance between breaking bad news, responding to patients’ and families’ emotional needs, and preserving the therapeutic alliance [4–6]. Conversations may be avoided or made more challenging in the context of heightened emotion. For example, patients’ anxiety may impede open discussion of prognosis as well as understanding of prognostic information [7–9]. Effective management of patients’ emotional reactions may promote their emotional adjustment, though empirical data linking in-the-moment responses to longer-term adjustment are limited.

Despite how common such challenges are, limited research addresses how best to manage patients’ emotional responses during prognostic discussions. Publications of communication skills training interventions often do not include details on techniques for managing specific emotional reactions, limiting utility for practicing clinicians and for testing them in subsequent research.

1.1. Areas Covered

To supplement American Society of Clinical Oncology guidelines for clinical communication [10], we offer a synthesis of common emotional reactions and approaches to addressing them. In this review, we detail common emotional reactions to hearing about poor prognosis, and suggest tools for clinicians to use during clinical visits. Although these specific recommendations have not yet been empirically tested in the context of prognostic discussions, we draw upon psychology literature, principles of skilled clinical communication, and published approaches to serious illness discussions (e.g., SPIKES [11], NURSE [12], Serious Illness Care Program [13]). We also aim to spur research in this area, such as vetting approaches with patients and studying their effect on patients’ adjustment to and understanding of their cancer prognosis.

2. Addressing common reactions to discussions of poor prognosis

A wide variety of emotional responses occur when patients receive news that their cancer is progressing, the end of their life is near, or their cancer is incurable. These emotional reactions are often complex and may include several mixed emotions (e.g., anxiety and sadness, shock and some degree of acceptance) that may co-occur and are likely to change over time. Patients also engage in efforts to change or manage their own emotions, either pre-emptively or in response to bad news. The ways in which patients cope with their emotions also impacts their caregivers [14], who often report similar or higher levels of anxiety compared to patients [14–16]. Similarly, clinicians may manage patients’ and caregivers’ emotions through inter-personal emotion regulation [17, 18].

Empathic responses, such as acknowledging and validating the patient’s emotional reaction, are crucial for psychologically-sensitive discussions and are described extensively in existing communication interventions [11, 19, 20]. Another crucial step is to recognize the patients’ emotional experience, which can be done by naming the emotion when it is clearly expressed (e.g., “I can see how sad this news has made you.”) or inquiring when it is unclear (e.g., “Can you help me to understand what’s going through your mind right now?”), as described in the NURSE approach [12]. Building upon these foundational skills, there is also growing support that emotion-regulation flexibility, or using different strategies to manage emotion in different contexts, leads to optimal regulation of emotions [21, 22]. Yet, varied responses to specific emotions and clinical contexts are less developed. Accordingly, we detail common reactions below and in Table 1, and provide suggestions for responding to them. These common emotional reactions and coping strategies often operate in both helpful and unhelpful ways (e.g., easing emotions while hindering the conversation). Our goal in suggesting clinician responses is to optimize the likelihood that patients not only will “know” or understand information about their cancer but also “feel known” as people [4] capable of coping and making medical decisions with their loved ones and clinical team.

Table 1.

Potential approaches to addressing patients’ emotional responses in discussions of poor prognosis.

Common patient response	Potential approach during visit	Key elements/rationale	Example
Sadness	Validation Acceptance-based strategies	Sadness is a natural response to upsetting news. Efforts to avoid negative emotions often elongate them or interfere with our values. Validate the patient’s emotions in the discussion without trying to change them or change the subject. Help the patient find ways to act in accord with values “alongside” negative emotions. [24]	“The sadness you’re feeling makes sense. For many patients, this is the most difficult news to get. I will continue to be here to support you.” “I know that [milestone mentioned] is very important to you, and the idea of missing it is devastating. Even though it’s certainly not the same, I wonder if we could try to think together about ways you can honor this special occasion now.”
Anxiety	Brief relaxation exercise Manage uncertainty	Physical arousal can exacerbate anxiety, and vice versa. Calming the body can help to reduce one’s negative thoughts and emotions by bringing arousal to a more manageable level. When the patient identifies his/her key worries, providing information about what to expect (when possible) can help to reduce uncertainty, which often elevates anxiety.	“This type of news is overwhelming, so I can see why you are feeling upset. [Pause and empathize further if needed]. Sometimes it can help to give ourselves a moment to slow down when things feel out of control. Are you open to taking a few slow breaths with me? 1…out…2…out…” “I imagine there are worries on your mind – What makes you the most worried about this news?” “While there are some things out of our control, I and my team will be with you each step of the way. We will work together in anticipating, as much as possible, what’s going on and what the future holds.”
Numbness, shock, or dissociation	Grounding exercise	Dissociation can occur when a person is overwhelmed by intense emotion. Noticing physical sensations in the “here and now” can help to re-center the person’s attention.	“It seems like your mind is far away right now. Let’s try to focus back on the moment by noticing a few sensations… Can you squeeze my hand? What about rubbing your hands together, and noticing that feeling? [Pause]. Now, I want to remind you where we were, talking about your scan results… ”
Anger or cynicism “So all this chemo has been for nothing!”	Validation Gentle cognitive reframing	Validating the patient’s anger can help to maintain rapport. At the same time, ruminating about the past can make a painful situation worse. After anger has subsided, and in a non-confrontational way, assist the patient with re-focusing on the present and future.	“This really isn’t the way we wanted it to be. I can see that you are frustrated, and I’m right there with you” “I wish it were different news – we made the best decision that we could at that time, with the information we had, so it’s very frustrating that we didn’t get the outcome we were hoping for. I want to do everything I can to help you take control of what is a very upsetting situation.”
Re-directing the conversation “I just don’t want to go there. I don’t want to talk about this.”	Motivational interviewing	Explore whether there is a “part of” the patient or family member that would like this information. Learn about ambivalence, and encourage “change talk” when a patient indicates information may be helpful. [50] Explain types of information available, and why you believe it may be helpful for the patient. Allow the patient to choose what type of information fits his or her needs at this time. Patients experience varying degrees of readiness for change. Pushing information when a patient does not want it can make them even more resistant to it. Change is most likely when patients collaborate and decide what is best for them, rather than a when a decision is exerted upon them by an authority figure.	“It sounds like you don’t want to talk about this. I hear that. Help me understand this more – What are your concerns about discussing it?” “Seems like there is a part of you that wants to know about [the future, etc], and a part that doesn’t. Can you tell me about each of those?” “I’d like to share what these results might mean for your illness. Some people like to know how much time they might have left, how well treatment is expected to work – or may have other questions. What information would be most helpful to you?”
Focusing on positive outcomes “I’m a fighter and I’m going to beat this.”	Teach-back Acceptance-based strategies	Cognitive biases can promote our tendency to focus only on “positive” information. Pause to allow processing, and clarify understanding of more difficult information before moving on to discuss what actions can be taken. [58, 59] There may be cultural or family-related expectations for maintaining a positive stance or a fighting spirit. Allowing this optimism to co-exist with other planning is likely to be more successful than confronting these engrained expectations in a short visit.	“Before we talk through options for next steps, I want to make sure we are on the same page about what these results mean. Can you tell me in your own words?” “You are certainly a fighter and are motivated to keep fighting this. I’m hoping for the best too - At the same time, it’s important to also help you prepare for the worse so that if we don’t get what we’re hoping for, we still have goals to strive for. So, I’d like to talk about what else is important to you about (pain; family; preparations; etc.) in addition to trying to beat this.”
Turning to religion or hope for a miracle “It’s in God’s hands, so there is nothing more to say.”	Validation Acceptance-based strategies	Validate the importance of the person’s faith.[66] Do not attempt to “disprove” the possibility of miracles. Rather, clarify the hope and propose ways you can assist in the present. [67]	“I can see how important your faith is, and that you are putting the future in God’s hands. At the same time, I am here to help you think of ways to achieve what is important to you now, in this moment. I’d like to help with [your pain; involving important family; etc.] - Can we talk about that for a few minutes?” “When you say you’re hoping for a miracle – Can you let me know more about what that miracle would look like? That way we can work together in that hope and all the while, be a team no matter what.”

2.1. Responding to common emotional reactions

2.1.1. Sadness

2.1.1.1. Potential impact on the clinical visit.

Sadness may reflect the patients’ acknowledgement of loss, such as a loss of the longer life they had envisioned or a loss of a sense of control or normalcy. Patients may express sadness when they are more aware of a poor prognosis [23]; clinicians may find it challenging to manage their own natural reactions (e.g., guilt, sadness) or may limit the conversation to avoid provoking more sadness.

2.1.1.2. Suggested strategy.

Validate sadness as an appropriate response to serious, upsetting news (instead of turning to positive topics or suggesting that the patient keep an optimistic outlook). Even a small gesture such as offering a tissue can demonstrate that sadness has been recognized and deemed important. Warmly emphasize continued commitment to caring for the patient and help to identify other existing social supports, demonstrating that he or she is not alone in the path ahead [4, 12]. Next, collaboratively identify meaningful actions by discussing the patient’s challenges, roles, and values [24].

2.1.1.3. Rationale.

Allowing patients to express their sadness, and joining them in this, signals that the feeling is natural and that the clinic is a safe place to express emotion. This approach is consistent with acceptance-based coping, or allowing feelings to be present without resisting or judging them. Compared to suppressing negative emotions, allowing them to be present can help dampen their intensity [25, 26] while promoting rapport and social support [27]. On the other hand, shifting the conversation to positive topics can minimize the gravity of the situation or contribute to confusion. In addition, exploring the patient’s values that are connected to this sadness can pinpoint meaningful activities that help to facilitate adjustment, promote values-based living, and foster a sense of control in an often-uncontrollable situation [24, 28].

2.1.2. Anxiety

2.1.2.1. Potential impact on the clinical visit.

Patients who are anxious may be more likely to avoid distressing information about their illness; alternatively, they may seek additional information in a search for reassurance [29, 30]. Anxiety may interfere with accurate understanding of information discussed [9], and decrease the likelihood of prognostic discussions [7].

2.1.2.2. Suggested strategy.

Pause and validate that it makes sense for the patient to feel worried or overwhelmed in response to this information. If appropriate (i.e., without invalidating the patient’s experience), explain that patients can sometimes find it helpful to take a few calming breaths to re-center when feeling overwhelmed, and ask if they are comfortable trying a few deep breaths with you. Inquire about the patient’s biggest worries and provide information about what to expect (i.e., try to reduce uncertainty) when possible. Acknowledge that it can be difficult to take in information when feeling upset, and encourage note-taking, provide a take-home summary of the information, or offer to revisit the topic at the next appointment if needed.

2.1.2.3. Rationale.

Anxiety is often accompanied by physical symptoms, including elevated heart rate, shallow breathing, and sweating, which can exacerbate emotional discomfort. Brief relaxation techniques such as deep breathing can engage the parasympathetic nervous system, dampening anxiety [31, 32]. While deep breathing has been used effectively in primary care and palliative medicine [33, 34], care is needed to avoid invalidating the patient’s anxiety and further research to test its use in prognostic discussions would be beneficial. Uncertainty typically elevates nervousness [35, 36]. It can be helpful to provide the patient with information that addresses his or her key “what if” questions [37] when possible, or collaboratively identify ways to cope when answers are unavailable.

2.1.3. Anger

2.1.3.1. Potential impact on the clinical visit.

When patients express anger and dissatisfaction, clinicians may be inclined to respond defensively, which can exacerbate anger and threaten therapeutic relationships [38].

2.1.3.2. Suggested strategy.

To prevent exacerbations in anger and ruptures in the patient-clinician alliance, resist the urge to defend your view or prior choices. Remembering that the patient’s anger is a natural and reasonable reaction to their situation, rather than a personal attack, can foster an adaptive response [39] such as non-judgmentally acknowledging the patient’s anger [40]. Use “I wish…” language (e.g., “I wish it were different…”) to validate the patient’s frustration [41], then explore sources of frustration and express support. After significant validation has been offered, if the anger has subsided, gently bring the focus back to the present moment to identify ways to address these frustrations or to weigh current options.

2.1.3.3. Rationale.

Compared to argumentative responding, validating the patient’s anger at the outcome can preserve trust and rapport. For example, common thought patterns that elevate anger include focusing on what “should have” occurred or how the situation could have been avoided [35, 42]. When anger is not escalating, presenting ways to re-focus on the present and future (while taking care not to dismiss the patient’s experience) can create distance from the past-oriented thoughts that often maintain anger or self-blame [43].

2.1.4. Numbness or shock

2.1.4.1. Potential impact on the clinical visit.

In this state, patients are unlikely to process further information extensively in the visit. They may stare blankly or not respond appropriately to the dialogue. Less overt responses may be more challenging to detect, such as appearing calm or stoic in response to news that would be expected to evoke a stronger emotional response.

2.1.4.2. Suggested strategy.

Notice behavioral signals, such as gazing away and becoming quiet, and ask the patient whether he or she is feeling shocked, overwhelmed, or numb. After validating the patient’s response, gently direct his or her attention to other aspects of the moment, such as physical sensations (e.g. feeling their feet on the floor, hearing the sound of your voice). These types of grounding exercises can create needed distance from painful emotions, so that attention can be re-directed back to the discussion.

2.1.4.3. Rationale.

Dissociation and numbness are common responses to feeling overwhelmed, and can protect against intense emotions in a threatening situation [44]. Pausing and gently redirecting the patient’s attention to physical sensations can allow them the space to shift attention away from their inner emotional experience and re-focus on the present moment [45].

2.2. Responding to common coping strategies

2.2.1. Re-directing the conversation

2.2.1.1. Potential impact on the clinical visit.

To avoid unpleasant emotions, patients may try to circumvent potentially upsetting topics. They may re-direct the conversation, repeatedly ask about alternatives, or focus on less threatening medical details, suggesting that they may be having difficulty processing upsetting prognostic information. In the short term, this avoidance may lead patients to feel relieved because discomfort is averted [29]. However, redirection can lead to a pattern of non-discussion, complicating clinicians’ attempts to relay important information. In the longer term, this pattern may increase distress by limiting opportunities for patients to make peace with their prognosis and to reach value-consistent informed decisions about their care [46, 47].

2.2.1.2. Suggested strategy.

To understand the patient’s hesitance to discuss a particular topic, use motivational interviewing strategies such as collaborating with the patient, evoking his/her views, and respecting his/her autonomy [48] (e.g., “It sounds like you don’t want to talk about this. Help me understand this more – What are your concerns about discussing it?”). Providing extensive information before a patient is ready to hear it may exacerbate avoidance [49]. Titrating the type and amount of prognostic information to patients’ preferences can introduce difficult topics in a manageable way [37].

2.2.1.3. Rationale.

People are often ambivalent about difficult changes [48]. Many patients may simultaneously want to hear it and not want to hear prognostic information [50]. Motivational interviewing can assist with this type of ambivalence [48]. When patients want to avoid hearing bad news, exploring resistance (rather than challenging it, or labeling it as “problematic” or “unreasonable” [51]) can give rich insight into what information may be desired and manageable to the patient at this time. Research suggests that patients find motivational interviewing strategies acceptable [52]. Helping patients to identify information that they are comfortable hearing may be helpful in several ways: those who have a better understanding of their prognosis are more likely to have high-quality, value-consistent end-of-life care [3, 53, 54], and patients who reduce their use of avoidant coping strategies also experience benefits in quality of life and depressive symptoms [55].

2.2.2. Focusing on positive outcomes

2.2.2.1. Potential impact on the clinical visit.

Maintaining optimism when confronting advanced disease can benefit psychological well-being and quality of life [56]. However, clinicians may be hesitant to introduce information that contradicts patients’ overly optimistic estimates, due to the perception that this may take away hope. Patients’ optimism may also influence clinicians, such that they are more likely to over-estimate survival time for more optimistic patients [57].

2.2.2.2. Suggested strategy.

Patients may be better able to process bad news when there are pauses for silence [58] or opportunities to discuss what the news means before shifting to more positive topics like treatment options [59]. For patients who continue to only focus on positive information, explore the patient’s sense of their current health status, and what it would be like if their health declined further [60]. Explain how you and the patient can simultaneously hope for the best and plan for the worst [61], showing that their positive outlook is not incompatible with future planning.

2.2.2.3. Rationale.

People often over-estimate the likelihood of positive outcomes for themselves, while under-estimating the likelihood of negative events, even in the presence of straightforward information [62]. The complexity of prognostic information, combined with patients’ numeracy skills and difficulty interpreting uncertainty, may make it even more challenging to understand accurately [63, 64]. Personal, cultural, and societal norms may reinforce the expectation that patients “stay positive” in the face of disease progression. In a short visit, challenging these engrained expectations is difficult. Assisting the patient in planning for negative outcomes alongside their strongly-held hopes may be more effective [61], allows the patient to consider the possibility of worsening disease in a distanced way, and does not diminish hope [65].

2.2.3. Turning to religion or hope for miracles

2.2.3.1. Possible impact on the clinical visit.

In an effort to be culturally sensitive, clinicians may refrain from clarifying information that may be discordant with expressed beliefs (e.g., hope for miracles).

2.2.3.2. Suggested strategy.

Acknowledge the importance of the patient’s faith, and highlight how you can deliver the high-quality care to them within the context of their beliefs [66]. When patients express hopes for a miracle, seek additional information by asking them to describe more details about what they are hoping for, in order to gain an understanding of whether the belief stems from acceptance, disbelief, or mistrust [67].

2.2.3.3. Rationale.

Spirituality and religion can be sources of comfort and acceptance that enable people to embrace the end of life peacefully. There are also situations in which patients may limit engagement in discussions because of their religious or spiritual beliefs, which in turn can impact understanding and acceptance of their illness [68, 69]. Patients’ hopes for miracles are diverse in their function and can have differential impacts on their health decisions; inquiring about them can help underscore their importance while clarifying the nature of the belief [67].

3. Expert Opinion

Transient emotional responses are natural and should be expected in clinical discussions of poor prognosis. Accordingly, the presence of negative emotion does not indicate that a visit has gone awry. Rather, these reactions may indicate patients are attempting to make sense of the information that was conveyed, and can foster meaningful interactions between clinicians and patients. Interventions to increase the frequency of prognostic discussions, or to convey information more effectively to patients, are unlikely to be successful without also attending to patients’ emotional reactions [70]. While psychologically-sensitive approaches exist, appropriate responses to patient emotions are not elaborated upon extensively in current interventions that promote prognostic discussions. Above, we have offered approaches for responding to patients’ specific emotional reactions and coping strategies that often manifest during these conversations. Themes involve (1) validating the patient’s emotion, (2) pausing to give time to process the information, and (3) collaborating to develop a plan that engages patient values and addresses their needs, using emotions as a guide in identifying what is important to the patient.

It is natural for medical professionals to feel continued discomfort with these conversations and concern over patients’ emotional well-being. In fact, these are valued reactions that promote humanistic medicine. A difficult clinical reality is that oncologists cannot reasonably be expected to completely resolve emotional reactions in a brief visit. On the other hand, attempting to avoid emotional reactions can exacerbate difficulties in and outside of the visit. Responding in psychologically-sensitive ways may help to reduce emotional intensity so that a conversation can continue.

When clinicians normalize emotional responses and introduce coping strategies in the visit, it may also create buy-in from patients to engage in longer-term psychosocial services if indicated. While a patient’s emotional response in the visit alone does not typically warrant a mental health referral, a referral is indicated if the patient’s emotional reactions are marked or long-lasting enough to upset them or their loved ones, or to interfere with daily functioning such as connecting with family or engaging in meaningful activities. While taking care to not pathologize reactions, the mere act of offering referrals can normalize the pain associated with a poor prognosis (e.g., “You’re going through so much – many of my patients find it helpful to speak with someone about these emotions, to help process all of it.”). For those with more extreme emotional reactions, appropriate mental health care can make the seemingly unbearable more bearable.

3.1. Five Year View

The future holds promise for effectively addressing patients’ emotional responses to bad news. Research agendas highlighting the importance of determining effects of emotions on clinical discussions and decisions [71, 72] and effective implementation of distress screening and referral protocols [73] will aid in these efforts.

To inform clinical approaches, future research should aim to identify factors that predict patients’ reactions to bad news, determine how emotional responses impact discussion dynamics and patient understanding, and investigate whether psychologically-sensitive strategies facilitate patients’ adjustment to poor prognosis. Given caregivers’ critical role in prognostic discussions and how their emotions interact with those of the patient, further investigation of caregivers’ emotional reactions during clinical visits is also warranted [70]. Burden of assessment is a key barrier to this work, although audiotaping and coding of clinical visits provide avenues for answering these questions. While a sensitive and brief approach to this research is certainly necessary, measuring distress reflects its conceptualization as a “vital sign” and promotes opportunities to prioritize emotional health.

With implementation of National Comprehensive Cancer Network distress screening and referral across the cancer continuum, patients who are most emotionally reactive may be identified earlier in the disease course, and learn tools to cope proactively. These strategies could ideally assist them during and following conversations about poor prognosis. Electronic- and mobile-health tools have the potential to relay pre- or post-visit assessments to clinical staff, which may assist with tailoring visits [73]. Clinics could increase collaboration with psychosocial oncology services for visits in which poor prognosis is discussed, particularly for patients with challenging emotional responses. For example, it may be helpful to apply examples from other integrated care models in which behavioral health providers are available for warm-handoffs (e.g., primary care; [74]), such that patients can go “just down the hall” for additional time and psychosocial oncology expertise devoted to assisting with distress management. Reimbursement structures and institutional policies would be needed to support these services.

Ongoing studies also show promise for leveraging other members of primary oncology teams to support behavioral health. While conducting prognostic discussions is appropriately the primary responsibility of medical oncologists, the team’s oncology nurses can also elicit patient values (including how they relate to a poor prognosis) and respond to emotions that may arise during such discussions [75, 76]. Primary oncology teams can also seek formal consultation from specialists in palliative care, psychosocial oncology, social work, psychology, and psychiatry [77].

Overall, with greater efficacy in managing emotional reactions to bad news, both clinicians and patients may be more willing to broach these discussions and the discomfort that comes with them. This may aid in earlier, more frequent, and more transparent discussions of prognosis, thereby promoting patients’ adjustment to their illness and improving the quality of end-of-life care for those with cancer.

Article highlights.

• Discussions of poor prognosis in advanced cancer are among the most challenging situations in clinical oncology, because patients receive information that represents a serious threat to their well-being and survival. Clinicians are understandably concerned about patient distress during these clinical visits, yet approaches to managing emotional responses are under-addressed in the literature on prognostic discussions.

• Transient emotional responses are natural and should be expected in clinical discussions of poor prognosis. These common responses often operate in both helpful and unhelpful ways, and impact how the clinical visit unfolds.

• Common emotional responses to discussions of poor prognosis include sadness, anxiety, anger, and shock or numbness. Patients may respond with common coping strategies such as re-directing the discussion, focusing on positive outcomes, and turning to faith or hope for miracles.

• Interventions to increase the frequency of prognostic discussions, or to convey information more effectively to patients, are unlikely to be successful without corresponding attention to the emotional responses prompted by these discussions.

• The present synthesis offers approaches for responding to patients’ specific emotional reactions and coping strategies that often manifest during these conversations. Themes involve (1) validating the patient’s emotion, (2) pausing to give time to process the information, and (3) collaborating to develop a plan that engages patient values “alongside” these emotions.

• Researchers should work to characterize the variety of real-time patient responses to poor prognosis, determine the effect of emotional response on elements of the discussion and patient’s understanding, identify factors that predict patients’ responses to bad news, and investigate whether psychologically-sensitive strategies are beneficial for patients’ adjustment to news about poor prognosis.

• Distress screening and referral across the cancer continuum may help to identify patients who are likely to be most emotionally reactive earlier in the course of their disease, and learn tools to cope proactively. In addition, utilizing electronic- and mobile-health tools, implementing integrated care models, leveraging other members of primary oncology teams, and consulting with specialists in behavioral health and palliative care hold promise for identifying and supporting patients’ emotional needs in the face of poor prognosis.

• With greater efficacy in managing emotional reactions to bad news, both clinicians and patients may be more willing to broach these discussions and the discomfort that comes with them, thereby assisting patients with adjustment to their illness and improving the quality of end-of-life care for those with cancer.