Beyond breaking bad news

Abstract

Hope is important to patients, yet physicians are sometimes unsure how to promote hope in the face of life-threatening illness. Hope in medicine is of two kinds: specific (hope for specific outcomes) and generalized (a nonspecific sense of hopefulness). At the time of diagnosis of a life-ending condition, the specific goal of a long life is dashed, and there may be no medically plausible specific outcome that the patient feels is worth wishing for. Yet the physician may nonetheless maintain an open-ended hopefulness that is compatible with the physician's obligation to be truthful; this hopefulness can help sustain patient and family through the turbulent period of adaptation to the unwelcome reality of major illness. As this adaptation evolves, the physician can help patients and families adapt to suffering and loss of control by selecting and achieving specific goals such as improvement of the patient's environment in hospital or hospice, pain control, and relief of sleeplessness. Thus hope for specific (but far more modest) future events can again become a positive part of the patient s emotional landscape. The authors do not propose that physicians remain upbeat no matter the circumstance, for they must respect the constraints of reality and the patients' mortality. However, physicians can provide both cognitive and affective support as patients learn how to adapt. Hope and hopefulness are both important in this process. Hope is always important to patients. Physicians can and should promote hopefulness without endorsing unrealistic hope.