Breaking Bad News

Breaking bad news is often seen as one of a clinician’s most difficulties responsibilities despite occurring on a semi-regular basis throughout their career. So, what exactly is bad news and how can we learn to improve the way we share it?

What is Bad News?

I’m sure you've thought of the obvious scenario; a fatal illness or the unexpected death of a family member. However, there are other situations which can be thought of as bad news. These situations could include cases where the diagnosis is unknown, or the prognosis is uncertain. In fact, there is no universal definition of what bad news is. Rather, it is a subjective term that will differ depending upon the perspective of the recipient. Simply put, news of any sort will mean different things to different people. If we had to have a go at defining bad news, it might be described as information that is ‘bad’, ‘sad’ or ‘difficult’. Alternatively, it could be any information that is not welcome, or any information which will adversely or seriously affects an individual’s view of their future. Whatever the information delivered, bad news has the potential to disrupt normal routines, shatter dreams and turn relationships upside down.

Personalising Bad News

Clinicians may find it difficult to break bad news because they are concerned how it will affect their patient. Previous paternalistic models recommended protecting patients from bad news in order to maintain their spirits in the face of difficulty. However, in recent years the newer models of patient autonomy advocate seeking a patient’s (or relative’s) view on the matter. While the majority of patients will want full disclosure, a not insignificant number may wish to remain protected from all the facts. For this reason, it is important to individualise the delivery of bad news by ascertaining how and to what extent the patient or relative would like the bad news to be addressed.

Difficulties in Breaking Bad News

The manner in which a patient responds to bad news is heavily influenced by their psychosocial context. For example, news which might otherwise be insignificant can become bad news if it occurs at an inopportune time such as during the week of a daughter’s wedding or perhaps a new relatively benign diagnosis which precludes certain activities, such as hay fever and signing up to become an RAF pilot or perhaps a lorry driver who has just has just had a seizure and will now lose their jobs. Getting to know your patients is an important step in knowing how they will respond to the news.

The clinicians themselves may find delivering bad news unpleasant and the complexity of the situation can create serious miscommunication. They don’t want to take away hope from patients, they may fear the reactions of relatives or they might be uncertain how to deal with intense emotional responses. These fears can induce anxiety or stress in the clinician and may lead to avoidance of distressing information or cause clinicians to convey unwarranted optimism. Despite all these difficulties, it is important to remember that the information is important in allowing patients to plan for their future.

Delivering Bad News Well

The way in which health professionals present bad news is an important factor for how it is received, understood and dealt with. When it is delivered poorly, the experience of receiving the bad news may remain long after the initial shock has passed. It is important that recipients of bad news should have access to timely, up-to-date, accurate and consistent information in a format and language that is appropriate to their particular circumstances and preferences. Studies have shown that the most important features of bad news delivery are the attitude of the person who gave the news, the clarity of the message, privacy and the ability of the news giver to answer questions. The patient or relatives will likely suffer additional stress if these conditions are not met and the news is delivered in a manner which lacks sensitivity.

Frameworks for Breaking Bad News

There are two common frameworks for breaking bad news. They are the SPIKES protocol and the ABCDE mnemonic. Both are described below. Despite their differences, they boil down into four main areas:

Preparation of self, of recipient and of environment.
Communication and the delivery of information.
Planning and agreement of what happens next.
Follow up with documentation, provision of written information and referral to other services.

SPIKES: A Six-Step Protocol

The SPIKES model was first published in The Oncologist in 2000 as a protocol for delivering bad news to cancer patients. Since then, it has become widely adopted across various specialties to deliver bad news. It consists of six steps as it gathers information from the patient, transmits medical information, provides support to the patient and elicits the patient’s collaboration in developing a plan for the future. Not every episode of breaking bad news will require all the steps, but where they do occur, they should be covered in order.

S - Set Up

Think about what you might say and rehearse how one will respond to the news.
Arrange for some privacy. Have some tissues ready in case.
Involve significant others. This should be the patient’s choice (up to one or two).
Sit down. This shows you have time and relaxes the patient. Remove any barriers between you.
Make a connection with the patient. Establish rapport by maintaining eye contact or touching the patient on the arm if they are comfortable with this.
Inform them of any time constraints or expected interruptions. Turn your phone off.

P - Perception

Use open ended questions to understand how the patient perceives the medical situation, whether it is serious or not and if they are in illness denial.
You can use this to correct misinformation and tailor bad news to what the patient understands.
Check that they are willing and able to hear what you will say.

I - Invitation

Most patients will indicate they want full disclosure, but some will shun it as a coping mechanism. Explicitly ask what the patient would want.
If patients do not want to have all the detail, offer to answer any questions they may have in the future or offer to talk to a relative instead.
You might discuss information disclosure at the time of ordering the investigation in preparation for the next step. “How would you like me to give the information about the test results?”

K - Knowledge

Warn the patient that bad news is coming. “Unfortunately, I’ve got some bad news to tell you”.
Use vocabulary that the patient will understand. Use non-technical words and avoid unnecessary jargon which could create a barrier to communication.
Be sensitive to how the patient is reacting and avoid excessive bluntness.
Give information in small chunks and check periodically their understanding.
If the prognosis is poor, avoid using phrases such as “There is nothing more we can do for you”. In these situations, it is still possible to offer other therapeutic goals such as pain relief.
Give the patient time and space to absorb information and ask questions.
Reassure the patient of ongoing support to help them cope and feel less isolated.

E – Empathy

Observe for any emotions. Don’t make assumptions about what the patient might be feeling. All patients are different.
Identify the emotions by naming it to oneself. Use open questions to find out what the patient is thinking.
Identify the reason for the emotion. It is usually the bad news, but it may be another reason.
Let the patient express their feelings and acknowledge that you have connected with the emotion.
Until an emotion is cleared, it can be difficult to discuss other issues. Continue to make empathic responses until the patient calms. If the patient is silent, you should ask exploratory questions before making an empathic response.

S – Strategy and Summary

Ask them if they are ready at that time for such a discussion. Share responsibility for decision-making.
Encourage patients to share their concerns. Clear plans make patients less anxious and uncertain.
Understand the important specific goals that patients have (i.e. symptom control) and make sure they receive the best possible treatment and continuity of care.
Check the patient’s understanding of the discussion to prevent patients from overestimating the efficacy or misunderstanding the purpose of the treatment.
Suggest the patient notes down any questions to discuss at the next meeting. Provide reading material when the patient is ready.
Give the patient information concerning next steps, including follow up or a realistic timescale of events. Let the know who is in charge of their care and how they can contact them.

ABCDE: A Mnemonic for Breaking Bad News

Described by Rabow and McPhee in their article ‘Beyond breaking bad news: how to help patients who suffer’. This mnemonic consists of five steps that can be used to help break bad news. They are as follows:

A – Advance Preparation

Familiarise yourself with the relevant clinical information. Be prepared to provide basic information about prognosis and treatment options.
Ask what the patient already knows and understands. What is their coping style?
Arrange for the presence of a support person and appropriate family member.
Arrange a time and private place that will be undisturbed. Give your bleep to someone to look after.
Prepare emotionally.
Mentally rehearse delivering the news and decide which words and phrases to use.

B – Build a Therapeutic Environment/Relationship

Introduce yourself and ask for the names of everyone and their relationship to the patient. Provide adequate seating for all.
Sit close enough to touch if appropriate. Be sensitive to cultural differences and personal preference.
Reassure about pain, suffering, abandonment. Assure them that you will be available. Schedule follow-up meetings and make appropriate arrangements.
Determine the patient’s preferences for what and how much they want to know.

C – Communicate Well

Be direct: "I am sorry, have bad news". Ask the patient or family what they already know or understand.
Speak frankly but compassionately. Avoid euphemisms, medical jargon and acronyms. Say "cancer" or "death".
Allow for silence and tears. Avoid the urge to talk to overcome your own discomfort.
Ask patient to repeat his or her understanding of the news. Encourage questions. At subsequent visits, check understanding and use repetition or corrections as needed.
Be aware that the patient will not retain much of what has been said. Write things down or draw sketches as needed.
At the conclusion of each visit, summarise and make follow up plans.

D – Deal with Patient and Family Reactions

Assess patient reactions. These might be physiological (fight, flight), cognitive coping strategies (denial, blame, intellectualisation, disbelief) or affective responses (anger, rage, fear, anxiety, helplessness, shame, relief, guilt, sadness).
Monitor the patient’s emotional status on subsequent visits.
Listen actively, explore feelings, express empathy. It is appropriate to say things such as “I’m sorry” or “I don’t know”.
Do not argue or criticise colleagues. Avoid defensiveness regarding the medical care that has been delivered.

E – Encourage and Validate Emotions

Offer to tell others on behalf of the patient.
Explore what the news means to the patient and evaluate the effect the news has had on them. Correct any misconceptions they might have.
Offer realistic hope about the treatment options available. Arrange follow up meetings for decision making.
Offer referrals as needed for interdisciplinary services to enhance patient care.
Address further needs and determine the patient's immediate and near-term plans.
Attend to your own needs during and following delivery of bad news. Process your own emotions.