BREAKING BAD NEWS

PERLA ANGELINA B. ILADA- AGAPAY, MD

The doctor – patient

relationship is founded on

trust.

It is fostered by honesty but

poisoned by deceit.

Breaking bad news

One of the physician’s most difficult duties

No formal preparation for this daunting task

Inadequate training may lead physicians to emotionally disengage with their patients

And yet, studies reveal that most

patients generally desire frank and

empathetic disclosure of a terminal

diagnosis or other bad news.

Breaking bad news

Definition

“Any news that drastically and negatively alters the patient’s view of his or her future”

“I left my house as one person and came home another”

Lance Armstrong

Breaking bad news is seldom a

question of “to tell or not to tell”,

but more of a matter of “when and

how to tell”.

Why is breaking bad news difficult? Fear of its effect on the patient

Hippocrates advised “concealing most things

from the patient while you are attending to him,

give necessary orders with cheerfulness and

serenity…revealling nothing of the patients

future or present condition. For many patients…

have taken a turn for the worst …by forecast of

what is to come.”

Traditional paternalistic models

“the doctor is always right”

“kayo napo ang bahala Dok, kayo

po ang nakakaalam”

Physician issues

1. In general, physicians do not wish

to take away hope from the patient

2. Physician’s uncertainty and

discomfort in delivering the bad

news

Difficult situations

Postoperative diagnosis of

malignancy

Imminent death

Sudden deaths

Young patients, specially children

Patients/relatives breaking down

Previously misinformed patient

Patient in denial

Wala na pong pag-asa

Difficult situations

SIX-STEP STRATEGY FOR BREAKING BAD NEWS (SPIKES)

STEP 1: S—SETTING UP the Interview Arrange for some privacy. Involve significant others. Sit down. Make connection with the patient.  Manage time constraints and

interruptions.

SPIKES Cont.

STEP 2: P—ASSESSING THE PATIENT'S PERCEPTION-

Important task of determining if patient is engaging in any variation of illness denial:

Wishful thinking, omission of essential but unfavorable medical details of the illness, or unrealistic expectations of treatment

SPIKES Cont.

STEP 3: I—OBTAINING THE PATIENT'S INVITATION

STEP 4: K—GIVING KNOWLEDGE AND INFOR- MATION TO THE PATIENT

STEP 4: K—GIVING KNOWLEDGE AND INFOR- MATION TO THE PATIENT

1. Start at the level of comprehension and vocabulary of the patient.

2. Use nontechnical words such as “spread” instead of “metastasized” and “sample of tissue” instead of “biopsy.”

3. Avoid excessive bluntness- leave the patient isolated and later angry, with a tendency to blame the messenger of the bad news

4. Give information in small chunks and check periodically as to the patient's understanding.

5. When the prognosis is poor, avoid using phrases such as “There is nothing more we can do for you.” - inconsistent with the fact that patients often have other important therapeutic goals such as good pain control and symptom relief.

(SPIKES Cont.) STEP 5: E—ADDRESSING

THE PATIENT'S EMOTIONS WITH EMPATHIC RESPONSESAn empathic response consists of four steps:1. Observe for any emotion on patient’s part.2. Identify the emotion experienced by the

patient by naming it to oneself.3. Identify the reason for the emotion.4. Let the patient know that you have

connected the emotion with the reason for the emotion by making a connecting statement.

Doctor: I'm sorry to say that the x-ray shows that the chemotherapy doesn't seem to be working [pause]. Unfortunately, the tumor has grown somewhat.

Patient: I've been afraid of this! [Cries]

Doctor: [Moves his chair closer, offers the patient a tissue, and pauses.] I know that this isn't what you wanted to hear. I wish the news were better.

(SPIKES Cont.)

STEP 6: S—STRATEGY AND SUMMARY Sharing responsibility for decision-

making with the patient may also reduce any sense of failure on the part of the physician when treatment is not successful. 

Communicating Bad News With

COMFORT

CommunicationOrientationMindfulnessFamilyOngoingReiterativeTeam

Six step protocol for breaking bad news

1. Getting the physical context right

2. Finding out how much the patient

knows

3. Finding out how much the patient

wants to know

4. Sharing information

5. Responding to patient’s feelings

6. Planning and following through

Six step protocol for breaking bad news

Getting the physical context right

Ensure that you have time

Private room

Silent mode

Sit down near the patient

Ascertain their current

understanding

What do they understand by the

words tumor or spot?

Finding out how much the patient knows

Finding out how much the patient wants to know

Are you the kind of person who

likes the full details or would you

prefer just to hear the treatment

plan?

“Hanggang saan po ninyo gustong

malaman?”

Sharing information

Use ordinary language, not

medical jargon

Check back on their understanding

Go at their pace

Allow pauses

Be emphatic and not be afraid to

say sorry or I don’t know

Use humor with care

Use drawings

Don’t argue

Sharing information

Responding to patients feelings

Listen, listen and listen

Questions should be encouraged

Planning and following through

Further meetings

Try to leave them with some hope,

remember, “may pag-asa hanggat

humihinga”

Communication

Prognosis

Depends on many factors

Patient ‘how long have I got doctor?

Doctor ‘I don’t know, and nobody

knows

Special instances

Care of the relatives

“You won’t tell him will you doctor?”

“We’d prefer you not to tell him

doctor”

Special instances

“The family cannot forbid the

doctor from discussing diagnosis

and prognosis with the patient.”

The ethics of medical

confidentiality states that relatives

can only be told with the explicit

permission from the patient and

not the other way around.

The key is to see both the patient and the

family initially apart from each other then

do a family meeting.

Tell the family that if the patient knows, it

is his opportunity to fix unfinished

business, and participate in his treatment.