Post on 26-Mar-2021
Breaking Bad News
Abdul-Monaf Al-Jadiry, MD,
FRCPsych
Professor of Psychiatry
What Is Bad News?
• ―Bad news‖ are any news that
drastically and negatively alters the
patient’s view of her or his future.
• Bad news is conventionally
associated with a terminal diagnosis,
but many other situations involve
imparting bad news
Breaking Bad News
• How a patient responds to bad news can be
influenced by the patient’s psychosocial
context:
- a diagnosis that comes at an inappropriate
time.
- a diagnosis that is incompatible with one’s
employment.
Breaking Bad News
• Patients generally desire frank and
empathetic disclosure of a terminal
diagnosis or other bad news.
• Focused training in communication skills
and techniques to facilitate breaking bad
news has been demonstrated to improve
patient satisfaction and physician comfort.
How Should Bad News Be Delivered?
To provide hope and healing to patientsreceiving bad news, the following stepswould facilitate the task
The mnemonic ―ABCDE‖ summarizes theimportant steps:
A = Advanced preparation
B = Building a therapeutic Relationship
C = Communicating well
D = Dealing with patient and family
reactions
E = Encouraging/validating emotions
A–ADVANCE PREPARATION
Familiarize yourself with the relevant clinical
information.
Have the patient’s chart or laboratory data on
hand during the conversation.
Be prepared to provide basic information.
about prognosis and treatment options.
Rehearse how you will deliver the news.
A–ADVANCE PREPARATION
• You may wish to practice out loud, as youwould prepare for public speaking.
• Script specific words and phrases to use oravoid.
• If you have limited experience deliveringbad news, consider observing a moreexperienced colleague or role play a varietyof scenarios with colleagues before actuallybeing faced with the situation.
A–ADVANCE PREPARATION
Arrange for adequate time in a
private, comfortable location.
Instruct office or hospital staff that
there should be no interruptions.
Turn your pager to silent mode or
leave it with a colleague
Prepare emotionally.
B–BUILD A THERAPEUTIC
ENVIRONMENT/RELATIONSHIP
Determine the patient’s preferences forwhat and how much they want to know.
When possible, have family members orother supportive persons present. Thisshould be at the patient’s discretion.
If bad news is anticipated, ask in advancewho they would like to be present and howthey would like the others to be involved.
Use touch where appropriate.
B–BUILD A THERAPEUTIC ENVIRONMENT/RELATIONSHIP
Some patients or family members willprefer not to be touched.
Be sensitive to cultural differences andpersonal preference.
Avoid inappropriate humor or flippantcomments; depending on your relationshipwith the patient, some discreet humor may
be appropriate.
B–BUILD A THERAPEUTIC ENVIRONMENT/RELATIONSHIP
Introduce yourself to everyone presentand ask for names and relationships tothe patient.
Foreshadow the bad news, ―I’m sorry, butI have bad news.‖
Assure the patient you will be available
Schedule follow-up meetings .
Advise appropriate staff and colleagues .
C–COMMUNICATE WELL
Ask what the patient or family already
knows and understands.
Find out the patient’s expectations before
you give the information.‖
Speak frankly but compassionately.
Avoid medical jargon. Use the words cancer
or death.
Allow silence and tears.
Avoid the urge to talk to overcome your
own discomfort.
Proceed at the patient’s pace.
C–COMMUNICATE WELL
Have the patient tell you his or herunderstanding of what you have said.
Encourage questions.
At subsequent visits, ask the patient if heor she understands, and use repetition andcorrections as needed.
Be aware that the patient will not retainmuch of what is said after the initial badnews.
Write things down, use sketches ordiagrams, and repeat key information.
At the conclusion of each visit, summarizeand make follow-up plans.
D–DEAL WITH PATIENT AND FAMILY
REACTIONS
Assess and respond to emotional reactions.
Be aware of cognitive coping strategies(e.g., denial, blame, intellectualization,disbelief, acceptance).
Be attuned to body language.
With subsequent visits, monitor thepatient’s emotional status, assessing fordespondency or suicidal ideations.
D–DEAL WITH PATIENT AND FAMILY REACTIONS
Be empathetic; it is appropriate to say ―I’msorry‖ or ―I don’t know.‖
Crying may be appropriate, but be reflective—are your tears from empathy with yourpatient or are they a reflection of your ownpersonal issues?
Do not argue with or criticize colleagues;avoid defensiveness regarding your, or a
colleague’s, medical care.
E–ENCOURAGE AND VALIDATE EMOTIONS
Offer realistic hope and encouragementabout what options are available.
Discuss treatment options at the outset,and arrange follow-up meetings for decisionmaking.
Explore what the news means to thepatient.
Inquire about the patient’s emotional andspiritual needs and what support systemsthey have in place.
Offer referrals as needed.
Use interdisciplinary services to enhancepatient care (e.g., hospice).
Example of a concluding scenario
• You do have cancer and it is a serious
illness but it is not necessarily a death
sentence, especially these days.
• You will need a major operation followed
by some treatment that will make you feel
very unwell but you can get through it.
•
• You are in good hands and you have lots
of people around who care about you.
Example of a concluding scenario
(cont…)
• If the worst does come to the worst we can
control pain without knocking you out and
without loss of dignity.
• You have a fight on and we can win.
• One of the most important features is your
attitude.
• Remember that if you have any problems or
want to discuss anything we are here for you.
Thank You