Breaking Bad News

KEYPOINTS

  • Entering difficult conversations can be challenging and stressful for all involved
  • Bad news can include any information that may seriously affect a person’s perception and experience of their future
  • How information is delivered has tremendous impact on how patients and family/caregivers hear the news, how they cope and how they make decisions
  • Everyone is unique in how they would like to be given information, what information they want to know and whom they want to know
  • Bad news is always “in the eye of the beholder”
  • It is difficult to estimate the impact of the bad news until one has learned the recipient’s expectations and understanding of the situation
  • Speaking openly and with compassion and empathy shows patients and family/caregivers you care

CONSIDERATIONS

Barriers to Breaking Bad News

Information sharing can be a complex communication skill.
The following are examples of experiences that may occur in the process of breaking bad news:

Health care professionals giving bad news

  • Fear of their own emotions
  • Fear of patient and family/caregiver emotions and reactions
  • Uncertainty in how to support these responses
  • Communicating information in technical language that is not easily understood
  • Avoiding discussion of distressing information
  • Giving false hope – telling patients and family/caregivers what they think they want to hear

Patients and family caregivers receiving bad news

  • Fear of what might be said
  • Not feeling prepared
  • Feeling that people are not being truthful or honest
  • Feeling that their decisions and hopes are not being respected
  • May only be able to take in information a little bit at a time
  • May have differences in what information they want each other to know
  • May have a need to seek a second opinion
  • May have limited understanding of medical/physical processes
  • May be embarrassed by own lack of knowledge

STRATEGIES

There are no universal approaches that will work in all situations when communicating bad news. When faced with the task, the following considerations may be helpful:

Preparation

  • Take time to reflect on your own feelings, emotions and concerns of the situation
  • Be familiar with background and details of participants (see Psychosocial Assessment)
  • Write down important points to be discussed and bring relevant health records
  • Come prepared to talk about possible next steps
  • Determine with the patient and family/caregivers who will be present
  • Choose a space that is private, comfortable, and limits opportunities for distractions and interruptions

Engaging in Conversation

  • Sit in a place that is most comfortable and supportive to the patient
  • Ask open-ended questions about what is currently known and understood about the situation (see Communication Strategies)
  • Provide honest and direct information in words that are easily understood
  • Pace the information and give time for silence; everyone processes information at different rates
  • Anticipate a range of feelings and emotions; patients and family/caregivers may have very different ways of responding to the news
  • Ask open-ended questions about how this new information has been understood
  • Discuss and address the immediate physical and/or psychosocial/spiritual needs
  • Discuss strategies and next steps; explore the hopes patients and family/caregivers may have at this time and for the future
  • Offer an opportunity for a follow-up meeting to address and clarify any concerns or new questions

Debriefing (Reflecting After the Meeting)

  • It is important that health care professionals pay attention to the range of feelings, responses and concerns they may experience after meeting with patients and family/caregivers (eg., sadness, frustration, anger, guilt, relief, uncertainty, helplessness, disagreement)
  • Discussing the meeting with team members is helpful because:
    • Perceptions and concerns of the event can be discussed
    • Support and suggestions from the team can be provided
    • New skills and awareness can be gained for future patient interactions
    • Debriefing helps build good team communication

SOURCES/REFERENCES

  1. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311. http://www.ncbi.nlm.nih.gov/pubmed/10964998
  2. Downing GM, Wainwright W, editors. Medical care of the dying. 4th ed. Victoria (BC): Victoria Hospice Society; 2006.
  3. Doyle D, Hanks G, Cherny N, Calman K, editors. Oxford textbook of palliative medicine. 3rd ed. Oxford: Oxford University Press; 2005.
  4. Gongal R, Vaidya P, Hayes B, Butterworth K. The handbook of palliative care. Hospice Nepal. Kathmandu, Nepal.
  5. Kirk P, Kirk I, Kristjanson L. What do patients receiving palliative care for cancer and their families want to be told: a Canadian and Australian qualitative study. BMJ 2004;328(7452):1343. http://www.ncbi.nlm.nih.gov/pubmed/15151964
  6. Watson M, Lucas C, Hoy A, Back I. Oxford handbook of palliative care. Oxford: Oxford University Press; 2005.

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