Breaking bad news1

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					Breaking Bad News:
   One of the most important jobs of
    a physician is to be a clear

   And one of the toughest challenges
    for a communicator is to deliver
    bad news.
   Communicating bad news to
    patients well is not an optional skill;
    it is an essential part of
    professional practice.
   “The bad news about breaking bad
    news is that bad news is bad

   Even though the message is bad,
    the messenger can be seen as part
    of the support system.
   Physicians frequently must break
    bad news to patients.
   According to one estimate, over the
    course of a career an oncologist
    will break bad news to patients
    about 20,000 times, from the first
    shocking facts of the diagnosis to
    the news that death is near.
What is meant by bad news ?
   Bad news is any information that
    adversely and seriously affects an
    individual’s view of his or her

   It is often associated with a
    terminal illness such as cancer.
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.
   a pregnant woman’s ultrasound
    verifies a fetal demise.
   a middle-aged woman’s magnetic
    resonance imaging scan confirms
    the clinical suspicion of multiple
   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.
   So bad news is a relative concept
    and the news may be considered to
    be bad by the patient and the
    family, if they feel that it is likely to
    adversely affect their future in
    some way.
What is difficult about giving bad
   Feel responsible and fear being
   Not know how to give the news
   Worry that is will change the
    existing doctor-patient relationship
   Fear the patient’s reaction on
    hearing bad news
   Uncertainty of what may happen
   Worry about not having answers to
    the questions that may be asked
   Worry about their own feelings and
    reaction to it
   Fear of doing it wrong or of giving
    the wrong information
   Whom to tell
   When to tell
   What to tell
   How to tell
   With regard to what to tell and how
    to tell the patient, there are two
    options. These are-
   Full disclosure ( to give the patient
    the full information)
   Individualized disclosure ( to use a
    flexible approach)
   In Asian cultures, individualized
    disclosure would be the best option
    to use.
Who should break bad news?
   Depends on the circumstances and
    their own level of competency.
   When giving the news of any life
    threatening disorder such as
    cancer, a senior member of the
    medical who has undertaken
    communication skills training
    should undertake the consultation.
    Ideally this should be a consultant.
   A nurse or other healthcare
    professional should accompany the
    doctor at this time.
The old concepts regarding
disclosure of bad news :
   Withholding bad news from
    patients was commonly practiced.
The recent trend :
   In recent decades, the paternalistic
    model of patient care has been
    replaced by one that emphasizes
    patient autonomy and full
    disclosure .
   Honest disclosure of diagnoses,
    prognoses, and treatment options
    allows patients to make informed
    healthcare decisions that are
    consistent with their goals and
    values .
How to break bad news?
   Key to breaking bad news well is to
    try to slow down the transition
    from a patient’s perception that
    they are well to a realisation that
    they have a life threatening or life
    changing disease.
   The various protocols have been
    developed for breaking bad news.
    The one described by Vandekieft in
    2001 follows the simple mnemonic
The ABCDE Mnemonic for
Breaking Bad News:
   Advance preparation:
- Arrange  for adequate time, privacy
 and no interruptions (turn pager
 off or to silent mode).
- Review relevant clinical
- Mentally rehearse, identify words
 or phrases to use and avoid.
- Prepare yourself emotionally.
   Build a therapeutic
-   Determine what and how much the
    patient wants to know.
-   Have family or support persons
-   Introduce yourself to everyone.
-   Warn the patient that bad news is
-   Use touch when appropriate.
-   Schedule follow-up appointments.
   Communicate well:
-   Ask what the patient or family
    already knows.
-   Be frank but compassionate;
    avoid medical jargon.
-   Allow for silence and tears;
    proceed at the patient's pace.
-   Have the patient describe his or
    her understanding of the news;
    repeat this information at
    subsequent visits.
-   Allow time to answer questions;
    write things down and provide
    written information.
-   Conclude each visit with a
    summary and follow-up plan.
   Deal with patient and family
-   Assess and respond to the patient and
    the family's emotional reaction; repeat
    at each visit.
-   Be empathetic ( objective awareness of
    and insight into the feelings, emotions,
    and behaviour of another person and
    their meaning and significance)
-   Do not argue with or criticize colleagues
   Encourage and validate emotions:
-   Explore what the news means to the
-   Offer realistic hope according to the
    patient's goals.
-   Use interdisciplinary resources.
-   Take care of your own needs; be
    attuned to the needs of involved house
    staff and office or hospital personnel.
   Other protocol such as the SPIKES
    protocol are also commonly used
    for breaking bad news.
The grief reaction:
   This follows five stages, identified
    by Kubler- Ross
   Denial and isolation
   Anger
   Bargaining
   Depression
   acceptance
   Stages do not necessarily occur in
    this order, and >1 stage can be
    present at once.
   Physicians need to individualize
    their manner of breaking bad news
    based on the patient’s desires and
   A physician’s attitude and
    communication skills play a crucial
    role in how well patients cope
    when they receive bad news.
“Breaking bad news is never easy
or pleasant: but at least having
some plan or approach increases
the professional’s feeling of
confidence- and that is often
perceived as increased
   Breaking bad news is a skill, which
    can be learnt and improves with
   Current medical diagnosis and
    treatment; 48th edition;2009
   Lecture notes in family medicine;
    Nandani de Silva
   Murtagh’s general practice; 4th
   Breaking bad news; American
    Family Physician; Dec 15, 2001

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