The art of presenting bad news vs. the risk of getting sued

No matter how busy physicians are when a pregnancy loss occurs, they should go to the mother's bedside to talk about the event for 10 minutes. Doing so just may "avoid 6 weeks in court," advised James R. Woods, Jr., MD, Henry A. Thiede Professor and Department of Obstetrics and Gynecology Chair at the University of Rochester, speaking at the ACOG District II/NY Annual Meeting in New York City.

But compassion-not fear of litigation-should be your motivation in following what Dr. Woods calls his "10-minute rule," he was quick to add. "Better communica-tion is not about trying to avoid lawsuits," but rather is fundamental to the practice of medicine.

In outlining strategies for communicating bad news in obstetrics, Dr. Woods acknowledged the challenge of teaching inexperienced young medical students whose lives may be relatively untouched by tragedy to appreciate the huge emotional toll a pregnancy loss takes on the entire family-and to anticipate a family's reactions. In addition, ultrasound technology has put more decision-making responsibility on the patient and expanded the definition of perinatal loss to include feelings of loss earlier in pregnancy (for example, the sudden dashing of dreams that often begin with first fetal ultrasound "portraits" and the loss of expected outcomes). Therefore, clinicians need to blend psychosocial skills with medical and communication skills to be able to counsel not just women who've had stillbirths or miscarriages, but also those whose babies are diagnosed or born with birth defects. Fortunately, the same strategies work for both, Dr. Woods said.

Because bad news can emerge early in a pregnancy during an ultrasound scan, he said, sonographers as well as ob/gyns need guidelines not taught in school on what to say when they discover an intrauterine death, for example. Dr. Woods, the author of several books on pregnancy loss and communicating unanticipated events, offered his "three sentence rule" for delivering such bad news as briefly as possible: "(1) Say it in one sentence (adding that you're sorry); (2) Explain it in one sentence; and (3) Repeat what you said."

Physicians reluctant to speak with patients due to medicolegal concerns about saying the wrong thing while "winging it" are often especially relieved to have guidelines about what to say, Dr. Woods finds. Just a few of the basic guidelines used at the Ultrasound Laboratory at his institution are: (1) Patients will feel reassured that it's no mistake-there's been no misdiagnosis-if the sonographer performs a thorough ultrasound scan even if a diagnosis of a fetal demise is obvious in a matter of seconds; (2) Simply state the diagnosis; (3) Show parents the U/S screen if they ask; (4) Dr. Woods sits with the couple for 10 minutes, but then gives them private time alone beside a phone, while he calls their ob/gyn; and (5) He has the couple return the next day to ask questions after the initial shock has worn off.

Woods JR. Strategies for communicating bad news in obstetrics. Presented at ACOG District II/NY Annual Meeting, October 28-30, 2005.