Preparation:

·         set up appointment as soon as possible

·         allow enough uninterrupted time; if seen in surgery, ensure no interruptions

·         use a comfortable, familiar environment

·         invite spouse, relative, friend, as appropriate

·         be adequately prepared re clinical situation, records, patient’s background

·         doctor to put aside own “baggage” and personal feelings wherever possible

Beginning the session / setting the scene

·         summarise where things have got to  date, check with the patient

·         discover what has happened since last seen

·         calibrate how the patient is thinking/feeling

·         negotiate agenda

  Sharing the information

·         assess the patient’s understanding first: what the patient already knows, is thinking or has been told

·         gauge how much the patient wishes to know [1]

·         give warning first that difficult information coming e.g. "I'm afraid we have some work to do...." "I'm afraid it looks more serious than we had hoped...."

·         give basic information, simply and honestly; repeat important points

·         relate your explanation to the patient’s framework

·         do not give too much information too early; don’t pussyfoot but do not overwhelm

·         give information in small “chunks”; categorise information giving

·         watch the pace, check repeatedly for understanding and feelings as you proceed

·         use language carefully with regard given to the patient's intelligence, reactions, emotions: avoid jargon

  Being sensitive to the patient

·         read the non-verbal clues; face/body language, silences, tears

·         allow for “shut down” (when patient turns off and stops listening) and then give time and space: allow possible denial

·         keep pausing to give patient opportunity to ask questions

·         gauge patient’s need for further information as you go and give more information as requested, i.e. listen to the patient's wishes as patients vary greatly in their needs

·         encourage expression of feelings, give early permission for them to be expressed: i.e. “how does that news leave you feeling”, “I’m sorry that was difficult for you”, “you seem upset by that”

·         respond to patient’s feelings and predicament with acceptance, empathy and concern

·         check patient’s previous knowledge about information given  

·         specifically elicit all the patient’s concerns

·         check understanding of information given ("would you like to run through what are you going to tell your wife?")

·         be aware of unshared meanings (i.e. what cancer means for the patient compared with  what it means for the physician)

·         do not be afraid to show emotion or distress

Planning and support                

·         having identified all the patient’s specific concerns, offer specific help by breaking down overwhelming feelings into manageable concerns, prioritising and distinguishing the fixable from the unfixable

·         identify a plan for what is to happen next

·         give a broad time frame for what may lie ahead

·         give hope tempered with realism (“preparing for the worst and hoping for the best”)

·         ally yourself with the patient (“we can work on this together  ...between us”) i.e. co-partnership with the patient / advocate of the patient

·         emphasise the quality of life

·         safety net

Follow up and closing    

·         summarise and check with patient

·         don't rush the patient to treatment

·         set up early further appointment, offer telephone calls etc.

·         identify support systems; involve relatives and friends

·         offer to see/tell spouse or others

·         make written materials available

  Remember doctor's anxiety  - re giving information, previous experience, failure to cure or help