Tips for Bad News Bearers

A Critical Clinical Skill

What is Bad News? Any news that

seriously and negatively alters the patient’s view of his or her future.

Buckman

The GoalHelp the patient and family

understand the condition Support the patient and familyMinimize the risk of overwhelming

distress or prolonged denial

Why is it a critical skill?The Patient’s Perspective

Patients often have vivid memories of receiving bad news

Negative experiences can have lasting effects on anxiety and depression

Can facilitate adaptation to illness and deepen the patient-doctor relationship

Why is it a critical skill?The Physician’s Perspective

High degree of difficulty + Physician anxiety =

High risk of performing poorly

What do patients want?For themselves…more time to talk and show feelings

From the doctor…more information, caring, hopefulness, confidencea familiar face Strauss 1995

What do you do?

What have you have found helpful in making “bad news” visits go as well as possible?

S etting up the interview

P erception of the patient re their illness

I nvitation from patient to share info

K nowledge and Information conveyed

E motions responded to empathically

S ummary and Strategy for follow-up

1. Setting up the interview

Anticipate the possibility of bad news, and arrange a follow-up visit after significant scans, biopsies etc.

Avoid telephone Private setting, sitting down Turn off beeper, no interruptions Ensure adequate time

1. Setting up the interview

Lab reports, X-rays present Support person present , if desired Review the condition, basic

prognosis and treatments before the visit

HOPEFUL TONE

Assessing the patient’s 2. PerceptionASK then TELLImportant if the patient is not well known to

you OR if visits to consultants have occurred

“Assess the Gap” between what the patient knows and the diagnosis

“What have you already been told about might be going on?

“What is your understanding of why the investigation was ordered?”

Obtaining the patient’s3. Invitation Preferably before the visitEasier if patient is well- knownListen to patient cues“Are you the sort of person who likes to

know all the details of your condition?“Would you like me to discuss the results

of the investigations with you?”

Giving 4. Knowledge and Information

Align yourself with the patient’s understanding and vocabulary

Start with a warning shot: “I’m afraid that the scan shows that the problem is fairly serious.”

Give diagnosis simply, avoid euphemisms or excessive bluntness

Provide information in small chunksCheck frequently for understanding

Giving 4. Knowledge and Information

Check for knowledge or experience with condition

Allow for pauses, use repetitionWill usually want basic but clear

information re treatment plan and prognosis

BUTTune into patient readiness to hear

more, and know when to stop

Balancing Truth and Hope: The Skillful Use of Indirect Language S Healing et al 2006

“It looks like….” not “You have….”“there are tumours in the liver…” not

“you have tumours in your liver…”

Emphasize on maintaining the relationship as well as communicating the news

Respond to 5. Emotions empathically

Observe for and allow emotional reactionsKleenex handy, use of touch

N aming the feeling “I know this is upsetting” U nderstanding “It would be for anyone” R especting “You’re asking all the right

questions” S upporting “I’ll do everything I can to help you

through this.”

6. Summary and Strategy for follow-up

Summarize discussionClear follow-up plan re: referral, tests,

next contact (in <48 hrs)Provide written summary or brochuresRefer to community resourcesInvite support person for next visit if

not present

6. Summary and Strategy for follow-up

End on note of hope and partnership AFTER: document well assess your own reaction

Six Steps for Breaking Bad News

S etting up the interview P erception of the patient re their illness I nvitation from patient to share info K nowledge and Information conveyed E motions responded to empathically S ummary and Strategy for follow-up

Discrepancies in Ratings

Patients rated the following much higher than doctor and nurses:

receiving bad news in a quiet, private placearranging a follow-up visit soon to review

with patient and familyinform patient about support services Girgis, Behavioural Medicine 1999

Follow-upPlease take a handout outlining the

SPIKES steps in sharing bad news

Try out one or two of the suggestions next time you have bad news to share

Remember

“The task of breaking bad news is a testing ground for the entire range of our professional skills and abilities. If we do it badly, the patients or family members may never forgive us; if we do it well, they will never forget us.”

Robert Buckman

Thank you!