last authored: Feb 2015, David LaPierre
Underlying Disorder, Julia Gibson, 2010
Breaking bad news is often an unfortunate necessity in health care. It wasn't until the 1960's that sharing news of a diagnosis such as cancer became widespread in the United States. In many countries and cultures, not sharing bad news remains the norm.
While receiving information of a diagnosis or prognosis can be devestating, its impact can be lessened if you are well-prepared and choose the setting, timing, and the devivery carefully.
Students in health care often find breaking bad news to be very uncomfortable for themselves personally, and have a framework for proceeding can help relieve anxiety about what is to come. Many students in health care receive little training in breaking bad news. An American study in 2002 found that 70% first gave bad news as medical students or interns. Attending staff were present 5% of the time, and debriefing rarely occurred (Orlander et al, 2002).
The information provided here will give guidance to lead to the most positive encounter possible for everyone during these difficult times.
The doctor's disease framework and the patient's illness framework can often be very different, but need to come together during the sharing of bad news. The following are important steps that can facilitate this.
Preparation for bad news can begin even before a test is done. While it is important to always be positive, do NOT trivialize potentially important tests before they are done (such as by saying "we won't find anything").
As you prepare, consider patient age, education level, language, culture and beliefs, current understanding, and what you understand they 'want' to know.
Encourage the patient to bring family and friends whenever possible, but make sure the patient wants them there. Example dialogue follows:
Involve other health care workers when appropriate. A nurse can be an effective support if the person is an inpatient.
Arrange to have information for them to take home, and begin making arrangements for follow-up as necessary even before your meeting.
Giving bad news can be extrememly difficult - prepare yourself emotionally.
Decide on what words and phrases you might use, especially for the opening line.
Anticipate seven frequent questions, and determine answers to them before the patient encounter:
The SPIKES Six-Point Protocol: another framework
for breaking bad news
When you recognize bad news will be likely, arrange an appropriate time to discuss. Meeting in person is important, as possible.
Make sure your meeting with the patient is prompt, and as close as possible to the time of diagnosis. However, it should not be rushed or hurried.
Provide privacy and confidentiality. Use the family room or other quiet space if possible, and draw curtains around the bed if on a ward if this is the only option. Ensure you provide adequate time. Sit close enough to touch, as deemed appropriate. Have a box of tissues present.
Ask what patient knows or fears. Build the narrative, reviewing history and tests that were done. Provide a warning, saying something like "we have your test result and it is worse than we expected".
Ask how much patient wants to know. A phrase to use could include: "Some people like to know a great deal; other people prefer to not have too much information. What would you like?" It can also be helpful to gauge this information early on in the investigations process.
Reactions can vary widely, and include overwhelming distress, denial, or unrealistic expectations, or acceptance. Focus your attention on the patient, assessing their reaction. Name and validate their emotions: "I see you are feeling...". Try to understand and appreciate the patient's predicament and feelings. Explore what the news means to the patient, and spend a great deal of time listening. Allow silence; pauses give patients space to speak and ask questions. Non-verbal communication can be helpful during these times.
Provide information in short, repetitive segments. Use understandable language, with quality and clarity and without euphemisms. For example, "Your nodes are positive, and the cancer is progressing" could sound like good news to patients, but is in fact ominous information signifying a worsening clinical picture.
Tell the truth.
Provide realistic hope. Acknowledge and address catastophizing. As you discuss follow up and next steps, help them find strength: "how have you coped in the past?" Identifying key people or support groups can be useful for many patients.
When discussing prognosis, recognize the limitations of statistics, and be vague as necessary. Acknowledge the limits of your knowledge.
Document the conversation in the chart.
Many people from various cultures feel compelled to shield their loved one from bad news. This poses an ethical dilemma in many cultures, as patient autonomy or right to know may appear to be compromised by this withholding of information. However, the motive is usually positive, and there is an ethical obligation to share with the patient only if they indeed want to know. As such, casually find out what their wishes are in conversation.
The death of Ivan Ilych, by Leo Tolstoy. - a novel about the end of life in which there is a conspiracy to avoid sharing news of a terminal disease.