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.”