Breaking bad news

Breaking bad news is part and parcel of being a doctor, for example, telling a patient that they have been infected with HIV. This can be a daunting and emotional process for both doctor and patient.

Bad news can plunge a patient into a confusing and alien situation that can destroy their dreams of the future. Usually doctors then speak medical jargon and subject them to tests and interventions that they may not actually understand. The ineffective delivery of bad news can have a long term negative impact on patients. 1

This skill forms part of core medical training within communication skills modules and you might find yourself having to break bad news in an OSCE station in medical school. 2 Unfortunately there is no easy way of doing this, and reading this will not make you an expert. This article aims to inspire you think about the best ways of breaking bad news and appreciating the complexity of doing this appropriately. We will use a cancer diagnosis as the ‘bad news’ in this essay for simplicity.

Preparation

Key points

• Gather information
• Recommend that loved ones or friends attend
• Ensure privacy
• Turn your phone/bleep off

First, learn all the information you can. This includes the patient’s age, background, past medical history, job, allergies etc. It sounds obvious but always check that you are talking to the right patient as mistakes do happen in hospitals. Nurses can be very helpful in providing additional details about how the patient has been doing recently and their feelings towards anticipated test results/appointments. 3 Become crystal clear about the diagnosis including the cancer grade (what cells look like microscopically), cancer stage (size and spread of tumour), prognosis and treatment options as patients may want to know. You could even rehearse the interview to help practice.

When receiving news that could affect the map they have of their future, having comforting people around and a soft unobtrusive environment would be ideal. If a nurse has established a relationship with the patient, having them join you in the consultation can benefit the patient and the nurse, who will need to care for the patient afterwards. 3 Patients have been shown to receive information well when bringing along loved ones or friends to the consultation was recommended. Therefore, an effort should be made to let the patient know in advance that they can do this. 4 Choose a quiet empty room with all doors and blinds closed to ensure privacy. Mobile phones and bleep should be turned off or left with a colleague who can attend to any calls. Longer appointments can also be booked to allow for the news to be broken gently, without rushing through it. 5

Beginning the consultation

Key points

• Explore their level of understanding, thoughts and feelings
• Determine how much they want to know

Approaching every patient in a tailored manner to suit their level of knowledge is useful. Some patients are very aware about their health and will want to know every detail about tests and the justifications for carrying them out. Others may not be aware that you carried tests to exclude cancer and therefore will not have the slightest clue as to what is coming. 3 The general principle is to establish the patient’s ideas, concerns and expectations, correct any misunderstandings such as wishful thinking or denial before breaking the bad news.

It is worth finding out how much patients would like to know about their diagnosis, allowing you to the trajectory for the pace and amount of detail and depth that you should break the news with. This varies between individuals again, with some responding with constant questioning and others only wanting to know what the best treatment option is. 6

Breaking the news

Key points

• Give small warning shots
• Pause and wait

Begin by giving a warning to the patient of imminent bad news, for example using the phrase ‘unfortunately I have some bad news’. This is called forecasting and limits disorientation, helps patients realize bad news is coming and limits the shock. 7 Make your message easy to digest by speaking slowly and clearly while avoiding medical jargon. If the patient stops you then resist the urge to keep talking and explain test results, as to them enough may be enough. Pause to give time for the news to sink in and wait for them to start the conversation again.

Being supportive

Key points

• Acknowledge emotions and respond with empathy
• Show you understand and that it is normal for them to react in the way that they do

It is the patients understanding, reactions, emotions, and behavior that actually determine the way that you should act and respond. Patients can react angrily, in disbelief, with tears, silence and even denial. 8 Therefore doctors need to be flexible and ready to respond in a way that they may never have before and never knew that they could.

The following four steps can be applied to make patients feel less isolated and to also demonstrate support and understanding. 9

  1. Observe the patient’s emotions and body language
  2. Acknowledge the emotions experienced by asking open ended questions such as ‘can you tell me how you are feeling’. This will help the patient open up and articulate how they feel. Give them time to speak.
  3. Identify the reason for their emotions ‘could you tell me more about it’ or ‘can you tell me what you mean’
  4. After letting them express their emotions, use validating phrases to not let them feel isolated and make them think that it is normal to feel this way ‘you are right to feel this way’ or ‘anyone else would feel the same’

Ending the consultation

Key points

• Summarise the main points
• Check patient’s understanding
• Invite questions
• Arrange for follow up appointment

Repeat the important pieces of information in a concise manner to help cement key points. Check that they understand and give them plenty of time to ask questions. 3 It is also important to inform them about your role in their future care and to inform other healthcare personnel including multidisciplinary teams and their GP. 5

It is clear that breaking bad news is a challenging aspect of being a doctor. If you find the process too emotionally difficult, it is important that you talk to colleagues or friends or access appropriate services such as social workers or chaplains. The BMA (British Medical Association) offers a 24 hours 7-day a week confidential advice and counselling service for doctors and medical students. 10

Nobody likes to break bad news and nobody wants to receive it, but sickness is unfortunately unavoidable. Remember to try to take the positives out of the experience and use it as an opportunity to reflect on your own skills and abilities to improve for the next time. Above all, remember to treat others in such difficult situations as you would wish to be treated yourself.

References

1 Fallowfield, L. 1993. Giving sad and bad news. Lancet, 341, 476-8.

2 Patient.info. 2014. Breaking Bad News. Help for Breaking Bad News [Online]. Patient.info. Available: http://patient.info/doctor/breaking-bad-news [Accessed 30/06/15 2015]

3 Thomas, J. & Monaghan, T. 2007. Oxford handbook of clinical examination and practical skills, Oxford, Oxford University Press.

4 Hanratty, B., Lowson, E., Holmes, L., Grande, G., Jacoby, A., Payne, S., Seymour, J. & Whitehead, M. 2012. Breaking bad news sensitively: what is important to patients in their last year of life? BMJ Support Palliat Care, 2, 24-8.

5 DHSSPS 2003. Breaking Bad News Regional Guidelines (National Council for Hospice and Specialist Palliative Care Services). In: Department of Health, S. S. a. P. S. (ed.).

6 Innes, S. & Payne, S. 2009. Advanced cancer patients’ prognostic information preferences: a review. Palliat Med, 23, 29-39.

7 Maynard, D. W. 1997. How to tell patients bad news: the strategy of “forecasting”. Cleve Clin J Med, 64, 181-2.

8 Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A. & Kudelka, A. P. 2000. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist, 5, 302-11.

9 Suchman, A. L., Markakis, K., Beckman, H. B. & Frankel, R. 1997. A model of empathic communication in the medical interview. Jama, 277, 678-82.

10 BMA. 2015. Doctors Well-Being [Online]. Available: http://bma.org.uk/practical-support-at-work/doctors-well-being [Accessed 30 2015].

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