442

Beyond Breaking Bad News

The Roles of Hope and Hopefulness

Simon N. Whitney, MD, JD1 BACKGROUND. Hope is important to patients, yet physicians are sometimes
Laurence B. McCullough, PhD
2 unsure how to promote hope in the face of life-threatening illness.
Ernest Fruge, PhD3 ANALYSIS. Hope in medicine is of two kinds: specific (hope for specific out-
Amy L. McGuire, JD, PhD4 comes) and generalized (a nonspecific sense of hopefulness). At the time of diag-
Robert J. Volk, PhD1 nosis 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
1
Department of Family and Community Medi- worth wishing for. Yet the physician may nonetheless maintain an open-ended
cine, Baylor College of Medicine, Houston, Texas. hopefulness that is compatible with the physician’s obligation to be truthful; this
2 hopefulness can help sustain patient and family through the turbulent period of
Center for Medical Ethics and Health Policy,
Baylor College of Medicine, Houston, Texas. adaptation to the unwelcome reality of major illness. As this adaptation evolves,
3
the physician can help patients and families adapt to suffering and loss of con-
Texas Children’s Cancer Center and Hematology
trol by selecting and achieving specific goals such as improvement of the
Service, Baylor College of Medicine, Houston,
Texas. patient’s environment in hospital or hospice, pain control, and relief of sleepless-
4
ness. Thus hope for specific (but far more modest) future events can again
Center for Medical Ethics and Health Policy,
become a positive part of the patient s emotional landscape. The authors do not
Baylor College of Medicine, Houston, Texas.
propose that physicians remain upbeat no matter the circumstance, for they
must respect the constraints of reality and the patients’ mortality. However, phy-
sicians can provide both cognitive and affective support as patients learn how to
adapt. Hope and hopefulness are both important in this process.
SUMMARY. Hope is always important to patients. Physicians can and should pro-
mote hopefulness without endorsing unrealistic hope. Cancer 2008;113:442–5.

2008 American Cancer Society.

Dr. Whitney is the William W. O’Donnell, MD and

KEYWORDS: adaptation, psychological attitude, attitude toward health, anxiety,
Regina O’Donnell Chair in Family Medicine. Dr.
Fruge’s work on this article was supported in medical ethics, interpersonal relations, physician-patient relations, decision.
part by a grant from the Arthur Vining Davis
Foundations.

We acknowledge the invaluable assistance of the

Hope Working Group in discussing the concept of
hope, including the authors of this article; Karen
Brisch, JD and Kristin Van Hook, MD, MPH; the
insightful comments of an anonymous peer
reviewer; and the contribution of Patricia Ser-
venti, who shared the compelling story of the
care received by her father and her family during
his last and only illness and who granted us per-
mission to publish and discuss her letter.
Address for reprints: Simon N. Whitney, MD, JD,
Department of Family and Community Medicine,
Baylor College of Medicine, 3701 Kirby Drive,
Suite 600, Houston, TX 77098-3926; Fax: (713)
798-7940; E-mail: swhitney@bcm.edu
Received January 7, 2008; revision received
March 11, 2008; accepted March 31, 2008.
T hat sick individuals need hope is widely accepted, but in a world
of evidence-based medicine, there is no algorithm to show how
the physician can help the patient find the right amount of the right
kind of hope. Yet we believe firmly that there are better and worse
ways to work with patients’ hopes and argue that what we cannot
prove to be true, patients and their families will tell us if we will
only listen. Consider the following letter.
In June of 1982, my father lay dying in Stanford Hospital of non-
Hodgkin lymphoma. It had been a very quick journey to this sudden
end. He was 58 and had always been healthy, never ill, until he collapsed
one morning, went to his doctor in Stockton, then to the hospital, then
to the grave, all in a matter of 3 weeks. It was shocking, totally unex-
pected, and deeply traumatic.
His condition baffled all of his medical experts until a lung biopsy
showed a rare and aggressive lymphoma. He was immediately put on

ª 2008 American Cancer Society

DOI 10.1002/cncr.23588
Published online 16 May 2008 in Wiley InterScience (www.interscience.wiley.com).

chemotherapy but was already gravely ill. No one was
hopeful. We knew the situation was dire, but we were
not ready to give up. We were not ready to treat him as
dead while he was still alive.
There was a young woman resident—we called her
the Grim Reaper. I don’t have to tell you what her stance
on hope was. She had none and would allow us none.
He was going to die; we needed to adjust. Fine, but we
weren’t ready yet, and was she God?
I didn’t want her in his room and felt nauseated ev-
ery time I saw her coming. I felt angry toward her for
her position. It seemed cold and totally unnecessary.
The fact that she was right in the end did not matter. It
was her manner, her lack of empathy, her failure to
understand our needs that bothered me.
At the same time, there was one particular young
doctor—the head resident of the internal medicine
team—who was extremely empathetic and understood
that we needed to hold out some hope for a positive
result, even if we knew that the chances of that occur-
ring were quite small. Essentially, we agreed that ‘where
there is life, there is hope.’ He more or less assured us—
we were weeping, he had tears—that it was not possible
to predict outcomes with medical certainty, that sicker
people had recovered and left the hospital, and we were
not out of our minds for holding on to some hope for a
good result.
We needed very much to hear this at the time. We
were not deluded. We did not hear this as meaning that
it was likely that he would recover. We could see how
sick he was, but we were in the middle of a nightmare
and needed just a modicum of relief from the unbear-
able sadness of our situation. Patricia Serventi
This narrative speaks to the importance of hope
at the time of an important life transition and to the
suffering that physicians can cause when hope is
seen as a delusion to be crushed. In this essay, we
consider the nature of hope and offer some prelimi-
nary thoughts about how an understanding of hope
may help physicians’ daily work with patients. We
begin with an exploration of 2 meanings of the word
‘hope.’
TWO KINDS OF HOPE
Hope may be either specific or generalized. Specific
hope (or particular hope1) is the state of desiring a
specific possible event or future state of affairs,
which is called the hope object. Hope objects (goals2)
reflect individuals’ varying beliefs, value systems, and
sense of possibility and vary over time as disease and
treatment progress. Hope objects in the clinical con-
text include not only prolonged life or cure but, as
expressed by 1 oncologist, the hope to enjoy the
Beyond Breaking Bad News/Whitney et al. 443
color and richness of daily experience, to control
pain, to be secure in the physician-patient relation-
ship. 3 Hope is distinct from faith, which, in the
context of illness, is a belief that life, with its una-
voidable loss and suffering, is always meaningful.
Specific hope varies along 2 dimensions: 1)
desire, whose strength may range from tepid to
intense, and 2) the perceived likelihood of the event
occurring, ranging from very low to nearly certain.4
To qualify as a hope object, the desired event or state
must be possible but not certain. The intensity of
desire for a hope object is independent of the per-
ceived likelihood of the event’s occurrence, for one
can strongly desire an unlikely event.
Generalized hope is described by Dufault and
Martocchio as the sense that there is some future
beneficial but indeterminate development that is
broad in scope and is not linked to a particular con-
crete or abstract object.1 In Helft’s words, generalized
hope is simply a sense of ‘open-endedness.’ 5 This is
what the Serventi family needed as they hoped for
any pause in the onrush of disaster. These 2 distinct
meanings of hope help explain how some physicians
impart hope to despairing patients and families even
when the chance of a good outcome is small.
Many of life’s challenges can be understood in
terms of the need to abandon 1 goal or hope object
and find something else with which to replace it as a
form of salvage.2 The adolescent whose vision is too
poor to be a pilot, the man whose beloved spurns
him for another, the couple who cannot conceive a
child: all must abandon cherished hope objects. Each
of us must accept a loss and find something new to
hope for many times over our lifetime. The suddenly
foreseeable extinction of our own life is among the
greatest of our losses of hope, and we turn now to
the interaction between patient and physician in this
existential crisis.
Bad News and a Crisis of Hope
The physician, as a diagnostician, often conveys bad
news. However, the physician’s role in breaking bad
news should not eclipse the patient’s role in hearing
and responding to it,6,7 because it is the patient who
must learn and grow, whereas the physician plays
only a supportive role.
Patients and their loved ones normally experi-
ence the onset of life-threatening illness as an evolu-
tion, not a single event,8 beginning with the first
suggestion that something is awry, continuing to di-
agnosis, to the patient’s and family’s adaptation to
that diagnosis, and on to their changed lives. Yet we
believe there is usually a moment at which the rea-
lity of the bad news first dawns on the patient, and
444 CANCER July 15, 2008 / Volume 113 / Number 2
that moment is often during a conversation in which
the physician formally provides a diagnosis or prog-
nosis. This conversation has at its heart 2 compo-
nents, disclosure and salvage.
The physician first describes the patient’s diag-
nosis and prognosis, steering a middle path between
‘undue bluntness or misleading optimism.’9 The
patient needs sufficient information to understand
the situation, at least at a basic level, and to partici-
pate in necessary decision making. Standard legal
doctrine emphasizes the importance of the factual
information conveyed during these discussions,10,11
but patients place great importance on the physi-
cian’s attitude and the manner in which he or she
conveys this important news.12,13
We believe that most physicians follow bad news
with attempts at salvage—statements intended to
reduce the impact of the bad news and help the
patient and family cope with a life-altering diagnosis,
such as reassurance that there are still treatments
that may prolong life and control symptoms. These,
in effect, are suggestions that the patient adopt new
hope objects (in this example, symptom control and
noncurative treatment). We believe that the physician
should not expect most patients to accept these
encouraging suggestions immediately; some time
must pass before a patient can abandon a primary (if
unconscious) hope object—continued life—and sub-
stitute an inferior but realistic hope object, such as
adequate quality of life. The physician must allow
time for the patient to accept these reduced hopes.
To do otherwise (and this was one of the Grim Reap-
er’s faults) may allay the physician’s own anxiety and
discomfort more than it serves the patient’s current
needs.
Physicians can help by focusing the discussion
not on nebulous long-term goals but on what can be
accomplished now. The physician who sets and
achieves specific goals contributes to the patient’s
physical and emotional comfort and alleviates
patient and family anger and anxiety. In the hospital,
the physician can practice this ‘medicine of the pos-
sible’ by controlling pain, barring unwanted visitors,
ensuring adequate sleep, keeping the room quiet,
and eliminating unnecessary interruptions (eg, vital
signs at midnight and 4 AM). Interventions of this
kind, undertaken in response to the patient’s stated
needs, give patients and families a modicum of con-
trol in a setting in which loss of control otherwise
seems absolute.
Some physicians eschew hopefulness and
attempt to ensure that the patient and family are
fully aware of the horror they face. The Grim Reaper
in the introductory letter is a prototype of this
model, with her toxic insistence that the family
embrace the harsh reality of their dire situation. We
do not know her reasoning, but her stance clearly
was unwise at the outset, and she should have chan-
ged it once it became clear that she was increasing
the family’s suffering. No physician should appear to
be death’s eager attendant.
Hope and Acceptance
After receiving bad news, the patient enters a turbu-
lent period of attempted accommodation to dramati-
cally changed life circumstances. This period may
end in denial, in anger, or in acceptance.14 We do
not believe that acceptance is the only valid way to
face death6 or that patients who reach acceptance
are superior to those who do not; however, accep-
tance is often an optimal outcome for patients and
their families.
The patient who reaches acceptance has inte-
grated the illness and the limitations it imposes by
establishing new priorities and finding a renewed
sense of purpose.2 This process is usually a challenge
that requires personal growth on the part of the
patient, perhaps assisted by family, friends, spiritual
advisors, and the physician. Acceptance cannot be
done to, or for, the patient; the patient must do it.
The work of acceptance can be framed in terms
of transition of hope objects. The prior implicit hope
for a long life must be converted to an explicit hope
for some extension of life; the previous freedom from
discomfort must be traded in for efforts of unknown
efficacy to reduce symptoms. This substitution of
hope objects is indeed painful. There are some
patients who accept news of a life-ending illness
with equanimity, but they are unusual; most patients
and most families suffer in the process. Patients who
succeed not only may accept the alternative hope
objects offered by the physician but may find pur-
pose in new hope objects, such as focusing on an
eternal life to come or recording a video history of
their life for a grandchild to ensure a legacy that will
be remembered.15
From the time of disclosure onward, we
hypothesize that the physician can bolster patient
and family hope by offering specific, alternate hope
objects in the hope that patients and families will
consider and eventually accept them and by main-
taining an open-ended, hopeful attitude—although
the situation is grim, there is always hope that things
will turn out better than expected. Medicine is an
inexact science; the timing and nature of biologic
events always retain an element of unpredictability.
Here, we focus on the cognitive aspects of hope
management, but we also want to emphasize the

profound importance of the behavioral and affective
components—of the physician recognizing and
responding to the patient’s emotional condition.12
When the physician forms an empathic emotional
connection with the patient, it conveys an unspoken
but important message of caring; the physician’s
steady presence is an almost physical shelter in the
emotional storm that often accompanies impending
death.
Promoting hope does not mean keeping patients
upbeat even when things are going badly, nor does it
mean preventing patients from ever experiencing
sadness: The news that one has a life-threatening ill-
ness or that an existing illness can no longer be con-
trolled provokes grief that cannot be prevented and
that the physician should not dismiss or try to sup-
press. At some point, weeks or months down the
road, most patients reach a new equilibrium in
which the new condition has become the status quo,
the changed expectations no longer cause grief, and
the patient once again hopes for a better tomorrow.
Physician awareness of the roles of hope and hope-
fulness may help in the journey.
REFERENCES
1. Dufault K, Martocchio BC. Symposium on compassionate
care and the dying experience. Hope: its spheres and
dimensions. Nurs Clin North Am. 1985;20:379–391.
2. Scheier MF, Carver CF. Adapting to cancer: the importance
of hope and purpose. In: Baum A, Anderson BL, eds. Psy-
chosocial Interventions for Cancer. Washington, DC: Amer-
ican Psychological Association; 2000:15–36.
Beyond Breaking Bad News/Whitney et al. 445
3. Delvecchio Good MJ, Good BJ, Schaffer C, Lind SE. Ameri-
can oncology and the discourse on hope. Cult Med Psychi-
atry. 1990;14:59–79.
4. Day JP. Hope. Am Philos Q. 1969;6:89–102.
5. Helft PR. Necessary collusion: prognostic communication
with advanced cancer patients. J Clin Oncol. 2005;23:3146–
3150.
6. Buckman R. How to Break Bad News: A Guide for Health
Care Professionals. Baltimore, Md: The Johns Hopkins Uni-
versity Press; 1992.
7. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka
AP. SPIKES—A six-step protocol for delivering bad news:
application to the patient with cancer. Oncologist. 2000;
5:302–311.
8. Schildmann J, Harlein J, Burchardi N, Schlogl M, Vollmann
J. Breaking bad news: evaluation study on self-perceived
competences and views of medical and nursing students
taking part in a collaborative workshop. Support Care Can-
cer. 2006;14:1157–1161.
9. Mueller PS. Breaking bad news to patients. The SPIKES
approach can make this difficult task easier. Postgrad Med.
2002;112:15–16, 18.
10. Berg JW, Appelbaum PS, Lidz CW, Parker LS. Informed
Consent: Legal Theory and Clinical Practice, 2nd ed. Oxford,
United Kingdom: Oxford University Press; 2001.
11. Annas GJ. Informed consent, cancer, and truth in progno-
sis. N Engl J Med. 1994;330:223–225.
12. Roberts CS, Cox CE, Reintgen DS, Baile WF, Gibertini M.
Influence of physician communication on newly diagnosed
breast patients’ psychologic adjustment and decision-mak-
ing. Cancer. 1994;74(1 suppl):336–341.
13. Parker PA, Baile WF, de Moor C, Lenzi R, Kudelka AP,
Cohen L. Breaking bad news about cancer: patients’ prefer-
ences for communication. J Clin Oncol. 2001;19:2049–2056.
14. Kubler-Ross E. On Death and Dying. New York, NY: Mac-
Millan; 1969.
15. Nuland SB. How We Die: Reflections on Life’s Final Chap-
ter New York, NY: Alfred A. Knopf; 1993.