breaking bad news

* have your facts right first

* meet in a quiet room
* meet in the presence of relatives or staff if possible
* use basic communication skills: use simple language, listen, follow up verbal and
non-verbal cues
* build up gradually
* be truthful, gentle and courteous
* offer hope
* emphasize the positive
* allow questions
* may need to have a number of meetings
* offer support
* document and inform others of what has been said
* follow up the patient

Don't:

* break bad news over the phone

* avoid the patient
* leave patient in suspense
* lie to the patient
* tell patient if he or she doesn't want to know
* interrupt excessively
* use jargon
* give excessive information as this causes confusion
* collude
* be judgmental
* give a definite time span (just say "days to weeks" or "months to years" etc
* pretend treatment is working if it isn't
* ever say "Nothing can be done"
* leave patient alone afterwards if at all possible

Breaking Bad News

A framework for breaking bad news

Preparation, Beginning the session / setting the scene , Sharing the information ,
Being sensitive to the patient , Planning and support Follow up and closing
References

Preparation:

· set up appointment as soon as possible

· allow enough uninterrupted time; if seen in surgery, ensure no interruptions

· use a comfortable, familiar environment

· invite spouse, relative, friend, as appropriate

· be adequately prepared re clinical situation, records, patient’s background

· doctor to put aside own “baggage” and personal feelings wherever possible

Beginning the session / setting the scene

· summarise where things have got to date, check with the patient

· discover what has happened since last seen

· calibrate how the patient is thinking/feeling

· negotiate agenda

Sharing the information

· assess the patient’s understanding first: what the patient already knows, is
thinking or has been told

· gauge how much the patient wishes to know [1]

· give warning first that difficult information coming e.g. "I'm afraid we have
some work to do...." "I'm afraid it looks more serious than we had hoped...."

· give basic information, simply and honestly; repeat important points

· relate your explanation to the patient’s framework

· do not give too much information too early; don’t pussyfoot but do not
overwhelm

· give information in small “chunks”; categorise information giving

· watch the pace, check repeatedly for understanding and feelings as you proceed

· use language carefully with regard given to the patient's intelligence, reactions,
emotions: avoid jargon

Being sensitive to the patient

· read the non-verbal clues; face/body language, silences, tears

· allow for “shut down” (when patient turns off and stops listening) and then give
time and space: allow possible denial

· keep pausing to give patient opportunity to ask questions

· gauge patient’s need for further information as you go and give more
information as requested, i.e. listen to the patient's wishes as patients vary greatly in
their needs

· encourage expression of feelings, give early permission for them to be

expressed: i.e. “how does that news leave you feeling”, “I’m sorry that was difficult
for you”, “you seem upset by that”

· respond to patient’s feelings and predicament with acceptance, empathy and

concern

· check patient’s previous knowledge about information given

· specifically elicit all the patient’s concerns

· check understanding of information given ("would you like to run through what
are you going to tell your wife?")

· be aware of unshared meanings (i.e. what cancer means for the patient
compared with what it means for the physician)

· do not be afraid to show emotion or distress

Planning and support

· having identified all the patient’s specific concerns, offer specific help by
breaking down overwhelming feelings into manageable concerns, prioritising and
distinguishing the fixable from the unfixable

· identify a plan for what is to happen next

· give a broad time frame for what may lie ahead

· give hope tempered with realism (“preparing for the worst and hoping for the
best”)

· ally yourself with the patient (“we can work on this together ...between us”) i.e.
co-partnership with the patient / advocate of the patient

· emphasise the quality of life

· safety net

Follow up and closing

· summarise and check with patient

· don't rush the patient to treatment

· set up early further appointment, offer telephone calls etc.

· identify support systems; involve relatives and friends

· offer to see/tell spouse or others

· make written materials available

Remember doctor's anxiety - re giving information, previous experience, failure to

cure or help

What is meant by bad news ?

Bad news is any information that changes a person's view of the future in a negative
way . It is often associated with a terminal illness such as cancer.(2)

However, bad news can come in many forms, for example :

· the diagnosis of a chronic illness (e.g., diabetes mellitus),

· disability, or loss of function (e.g., impotence);

· a treatment plan that is burdensome, painful, or costly;

· and even information that physicians may perceive as neutral or benign.

· a pregnant woman’s ultrasound verifies a fetal demise

· a middle-aged woman’s magnetic resonance imaging scan confirms the

clinical suspicion of multiple sclerosis,

· an adolescent’s polydipsia and weight loss prove to be the onset of

diabetes.

· It might simply be a diagnosis that comes at an inopportune time, such as

unstable angina requiring angioplasty during the week of a daughter’s wedding,

· or it may be a diagnosis that is incompatible with one’s employment, such as

a coarse tremor developing in a cardiovascular surgeon. (2,7)

The old concepts regarding disclosure of bad news :

* Robert Buckman, in an excellent short manual, has outlined a six step protocol for
breaking bad news. The steps are: (6)

1. Getting started :

* The physical setting ought to be private, with both physician and patient
comfortably seated.

* You should ask the patient who else ought to be present, and let the patient decide
(studies show that different patients have widely varying views on what they would
want).

* It is helpful to start with a question like, "How are you feeling right now?" to
indicate to the patient that this conversation will be a two-way affair.

2. Finding out how much the patient knows :

By asking a question such as, "What have you already been told about your illness?"
you can begin to understand :

* what the patient has already been told ("I have lung cancer, and I need surgery"),
* or how much the patient understood about what's been said ("the doctor said
something about a spot on my chest x-ray"),
* the patients level of technical sophistication ("I've got a T2N0 adenocarcinoma"),
* and the patient's emotional state ("I've been so worried I might have cancer that I
haven't slept for a week").

3. Finding out how much the patient wants to know :

* It is useful to ask patients what level of detail you should cover. For instance, you
can say, "Some patients want me to cover every medical detail, but other patients
want only the big picture--what would you prefer now?" This establishes that there is
no right answer, and that different patients have different styles. Also this question
establishes that a patient may ask for something different during the next
conversation.

4. Sharing the information :

* Decide on the agenda before you sit down with the patient, so that you have the
relevant information at hand.
* The topics to consider in planning an agenda are: diagnosis, treatment, prognosis,
and support or coping. However, an appropriate agenda will usually focus on one or
two topics.
* For a patient on a medicine service whose biopsy just showed lung cancer, the
agenda might be: a) disclose diagnosis of lung cancer; b) discuss the process of
workup and formulation of treatment options ("We will have the cancer doctors see
you this afternoon to see whether other tests would be helpful to outline your
treatment options").
 * Give the information in small chunks, and be sure to stop between each chunk to
ask the patient if he or she understands ("I'm going to stop for a minute to see if you
have questions").
* Long lectures are overwhelming and confusing.
* Remember to translate medical terms into English, and don't try to teach
pathophysiology.

5. Responding to the patients feelings :

* If you don't understand the patient's reaction, you will leave a lot of unfinished
business, and you will miss an opportunity to be a caring physician.
* Learning to identify and acknowledge a patient's reaction is something that
definitely improves with experience, if you're attentive, but you can also simply ask
("Could you tell me a bit about what you are feeling?").

6. Planning and follow-through :

* At this point you need to synthesize the patient's concerns and the medical issues
into a concrete plan that can be carried out in the patient's system of health care.
* Outline a step-by-step plan, explain it to the patient, and contract about the next
step.
* Be explicit about your next contact with the patient ("I'll see you in clinic in 2
weeks") or the fact that you won't see the patient ("I'm going to be rotating off service,
so you will see Dr. Back in clinic").
* Give the patient a phone number or a way to contact the relevant medical
caregiver if something arises before the next planned contact.

N.B. for more details : www.skillscascade.com/badnews.htm

www.fastcompany.com/online/23/buckman.html

Other guidelines and protocols :

(A) Girgis and Sanson-Fisher guidelines on conveying information to patients about

serious disease or death, include : (3)

* ensuring privacy
* allowing adequate time,
* assessing patients' understanding,
* giving information about diagnosis and prognosis simply and honestly, avoiding
euphemisms,
* encouraging patients to express feelings,
* being empathic,
* giving a broad but realistic time-frame concerning prognosis,
* arranging a review.

(B) Dr. Robert Arnold, an internist and communications expert at the University of
Pittsburgh, suggested: (4)
· "Name your emotions. And then acknowledge he doesn't have to have the same
ones."

· Find out who the patient is.

· Be direct. "Say 'Help me understand your story,' or 'Are you the kind of person
who likes to know all the details?"'

· "Figure out what kind of doctor your patient wants you to be."

(C) SPIKES: A mnemonic for breaking bad news to patients by Baile and colleagues

etting up

erception

nvitation

nowledge

motions

trategy and summary

www.postgradmed.com/issues/2002/09_02/editorial_sep.htm

(D) The ABCDE Mnemonic for Breaking Bad News by Rabow and McPhee
http://www.aafp.org/afp/20011215/1975.pdf
Other helpful phrases and questions are :

· "I wish I had better news" (as opposed to "I'm sorry, I have bad news"),

· "I admire your courage,"

· "I will be here for you,"

· "What gives you hope and strength?"

Unhelpful statements include :

· "It could be worse,"

· "We all die,"

· "I understand how you feel,"

· "Nothing more can be done." (2)

What if the patient starts to cry while I am talking?

In general, it is better simply to wait for the person to stop crying. If it seems
appropriate, you can acknowledge it ("Let's just take a break now until you're ready to
start again") but do not assume you know the reason for the tears (you may want to
explore the reasons now or later). Most patients are somewhat embarrassed if they
begin to cry and will not continue for long. It is nice to offer kleenex if they are
readily available (something to plan ahead); but try not to act as if tears are an
emergency that must be stopped, and don't run out of the room--you want to show that
you're willing to deal with anything that comes up. (6)

Finally it is obvious that acquiring the skill of breaking bad news greatly required
because 'How a physician delivers bad news may affect patients' understanding of and
adjustment to the news as well as their satisfaction with their physician'. (2)

The limits of medicine assure that patients cannot always be cured. These are
precisely the times that professionalism most acutely calls the physician to provide,
hope and healing for the patient. (7)