Diagnosis and Prognosis Discussions –The Harder Questions

(Disclosure — This was meant as an outline, but I accidentally sent it out — so given all the links it triggers, I thought I should keep it available.  I do plan a fuller discussion.  Thoughts are welcome.)

The first stuff on this is easy:  Patient and (assuming the patient agrees) the family are entitled to the truth, different people hear hard things best when told in different ways;  the clinician can not force people to know or accept more than they want or are able to do.

But then it gets harder.  As a patient, family member and friend, I have been involved in too many of these situations, and find myself still not knowing the answers to these questions.

How do you ensure that you actually have communicated the news, and its implications?

What happens when the patient seems ready to act on bad news that the family does not seem able to accept, and the patient can not or will not force the matter?

What happens when both in a couple seem to be suppressing bad news, and you suspect that each in trying to protect the other?

How do you find the best way to communicate bad news, particularly when you do not know the patient or family well?

What do you do when you think that you have communicated the news, but the patient and family seem not to have internalized it, or at least seem unable to act upon it?