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