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breaking bad news

* have your facts right first * meet in a quiet room * meet in the presence of relatives or staff if possible * use basic communication skills: use simple language, listen, follow up verbal and non-verbal cues * build up gradually * be truthful, gentle and courteous * offer hope * emphasize the positive * allow questions * may need to have a number of meetings * offer support * document and inform others of what has been said * follow up the patient Don't: * break bad news over the phone * avoid the patient * leave patient in suspense * lie to the patient * tell patient if he or she doesn't want to know * interrupt excessively * use jargon * give excessive information as this causes confusion * collude * be judgmental * give a definite time span (just say "days to weeks" or "months to years" etc * pretend treatment is working if it isn't * ever say "Nothing can be done" * leave patient alone afterwards if at all possible Breaking Bad News A framework for breaking bad news Preparation, Beginning the session / setting the scene , Sharing the information , Being sensitive to the patient , Planning and support Follow up and closing References Preparation: · · set up appointment as soon as possible allow enough uninterrupted time; if seen in surgery, ensure no interruptions

" "I'm afraid it looks more serious than we had hoped... records. silences. don’t pussyfoot but do not overwhelm · · give information in small “chunks”. emotions: avoid jargon Being sensitive to the patient · read the non-verbal clues.. friend. patient’s background doctor to put aside own “baggage” and personal feelings wherever possible Beginning the session / setting the scene · · · · summarise where things have got to date. familiar environment invite spouse. check repeatedly for understanding and feelings as you proceed · use language carefully with regard given to the patient's intelligence. reactions. tears · allow for “shut down” (when patient turns off and stops listening) and then give time and space: allow possible denial · keep pausing to give patient opportunity to ask questions . as appropriate be adequately prepared re clinical situation." · · give basic information. "I'm afraid we have some work to do.. is thinking or has been told · gauge how much the patient wishes to know [1] · give warning first that difficult information coming e. relative. simply and honestly. repeat important points relate your explanation to the patient’s framework · do not give too much information too early.· · · · use a comfortable. face/body language.g.. check with the patient discover what has happened since last seen calibrate how the patient is thinking/feeling negotiate agenda Sharing the information · assess the patient’s understanding first: what the patient already knows. categorise information giving watch the pace..

between us”) i. “I’m sorry that was difficult for you”.. prioritising and distinguishing the fixable from the unfixable · · identify a plan for what is to happen next give a broad time frame for what may lie ahead · give hope tempered with realism (“preparing for the worst and hoping for the best”) · ally yourself with the patient (“we can work on this together . empathy and concern · · check patient’s previous knowledge about information given specifically elicit all the patient’s concerns · check understanding of information given ("would you like to run through what are you going to tell your wife?") · be aware of unshared meanings (i.e.. “how does that news leave you feeling”.e.· gauge patient’s need for further information as you go and give more information as requested. i. listen to the patient's wishes as patients vary greatly in their needs · encourage expression of feelings. what cancer means for the patient compared with what it means for the physician) · do not be afraid to show emotion or distress Planning and support · having identified all the patient’s specific concerns. co-partnership with the patient / advocate of the patient · · emphasise the quality of life safety net Follow up and closing · · summarise and check with patient don't rush the patient to treatment . offer specific help by breaking down overwhelming feelings into manageable concerns.e. give early permission for them to be expressed: i. “you seem upset by that” · respond to patient’s feelings and predicament with acceptance.e.

a pregnant woman’s ultrasound verifies a fetal demise · a middle-aged woman’s magnetic resonance imaging scan confirms the clinical suspicion of multiple sclerosis. previous experience. · It might simply be a diagnosis that comes at an inopportune time. bad news can come in many forms.(2) However.7) The old concepts regarding disclosure of bad news : . such as a coarse tremor developing in a cardiovascular surgeon. such as unstable angina requiring angioplasty during the week of a daughter’s wedding.g.. a treatment plan that is burdensome. (2. disability.g. involve relatives and friends offer to see/tell spouse or others make written materials available Remember doctor's anxiety . and even information that physicians may perceive as neutral or benign. painful.. · or it may be a diagnosis that is incompatible with one’s employment. or loss of function (e. offer telephone calls etc. impotence). · an adolescent’s polydipsia and weight loss prove to be the onset of diabetes.· · · · set up early further appointment. It is often associated with a terminal illness such as cancer. diabetes mellitus). identify support systems. for example : · · · · · the diagnosis of a chronic illness (e.re giving information. failure to cure or help 4 What is meant by bad news ? Bad news is any information that changes a person's view of the future in a negative way . or costly.

* It is helpful to start with a question like. The steps are: (6) 1. and support or coping. with both physician and patient comfortably seated. treatment. However. 4. * You should ask the patient who else ought to be present. you can say. "What have you already been told about your illness?" you can begin to understand : * what the patient has already been told ("I have lung cancer. * the patients level of technical sophistication ("I've got a T2N0 adenocarcinoma"). . an appropriate agenda will usually focus on one or two topics. Sharing the information : * Decide on the agenda before you sit down with the patient. 2. For instance. * and the patient's emotional state ("I've been so worried I might have cancer that I haven't slept for a week"). and that different patients have different styles. * or how much the patient understood about what's been said ("the doctor said something about a spot on my chest x-ray"). Getting started : * The physical setting ought to be private. Also this question establishes that a patient may ask for something different during the next conversation. Finding out how much the patient wants to know : * It is useful to ask patients what level of detail you should cover. 3. and let the patient decide (studies show that different patients have widely varying views on what they would want). * For a patient on a medicine service whose biopsy just showed lung cancer. and I need surgery"). b) discuss the process of workup and formulation of treatment options ("We will have the cancer doctors see you this afternoon to see whether other tests would be helpful to outline your treatment options"). Finding out how much the patient knows : By asking a question such as. in an excellent short manual. so that you have the relevant information at hand. but other patients want only the big picture--what would you prefer now?" This establishes that there is no right answer. the agenda might be: a) disclose diagnosis of lung cancer. "How are you feeling right now?" to indicate to the patient that this conversation will be a two-way affair. prognosis.* Robert Buckman. has outlined a six step protocol for breaking bad news. "Some patients want me to cover every medical detail. * The topics to consider in planning an agenda are: diagnosis.

and be sure to stop between each chunk to ask the patient if he or she understands ("I'm going to stop for a minute to see if you have questions"). Back in clinic"). 6. but you can also simply ask ("Could you tell me a bit about what you are feeling?"). and you will miss an opportunity to be a caring physician. Responding to the patients feelings : * If you don't understand the patient's reaction. if you're attentive. * arranging a review. * Be explicit about your next contact with the patient ("I'll see you in clinic in 2 weeks") or the fact that you won't see the patient ("I'm going to be rotating off service.htm www. * being empathic.B. so you will see Dr.html Other guidelines and protocols : (A) Girgis and Sanson-Fisher guidelines on conveying information to patients about serious disease or death. * encouraging patients to express feelings. N. suggested: (4) . include : (3) * ensuring privacy * allowing adequate time.com/online/23/buckman. * Remember to translate medical terms into English. explain it to the patient. an internist and communications expert at the University of Pittsburgh.com/badnews.* Give the information in small chunks. and don't try to teach pathophysiology.fastcompany. * Outline a step-by-step plan. and contract about the next step. for more details : www. 5. Robert Arnold. * assessing patients' understanding. (B) Dr. Planning and follow-through : * At this point you need to synthesize the patient's concerns and the medical issues into a concrete plan that can be carried out in the patient's system of health care. * Give the patient a phone number or a way to contact the relevant medical caregiver if something arises before the next planned contact. * Learning to identify and acknowledge a patient's reaction is something that definitely improves with experience.skillscascade. avoiding euphemisms. * giving a broad but realistic time-frame concerning prognosis. * Long lectures are overwhelming and confusing. you will leave a lot of unfinished business. * giving information about diagnosis and prognosis simply and honestly.

And then acknowledge he doesn't have to have the same ones." · Find out who the patient is.pdf .· "Name your emotions.postgradmed.aafp.com/issues/2002/09_02/editorial_sep. "Say 'Help me understand your story.htm (D) The ABCDE Mnemonic for Breaking Bad News by Rabow and McPhee http://www.' or 'Are you the kind of person who likes to know all the details?"' · "Figure out what kind of doctor your patient wants you to be." (C) SPIKES: A mnemonic for breaking bad news to patients by Baile and colleagues S etting up P erception I nvitation K nowledge E motions S trategy and summary www. · Be direct.org/afp/20011215/1975.

If it seems appropriate." "What gives you hope and strength?" Unhelpful statements include : · · · "It could be worse. These are precisely the times that professionalism most acutely calls the physician to provide." "We all die." "I will be here for you.Other helpful phrases and questions are : · · · · "I wish I had better news" (as opposed to "I'm sorry. but try not to act as if tears are an emergency that must be stopped. it is better simply to wait for the person to stop crying." (2) What if the patient starts to cry while I am talking? In general. hope and healing for the patient. (6) Finally it is obvious that acquiring the skill of breaking bad news greatly required because 'How a physician delivers bad news may affect patients' understanding of and adjustment to the news as well as their satisfaction with their physician'. I have bad news"). "I admire your courage. (2) The limits of medicine assure that patients cannot always be cured." "I understand how you feel. It is nice to offer kleenex if they are readily available (something to plan ahead). you can acknowledge it ("Let's just take a break now until you're ready to start again") but do not assume you know the reason for the tears (you may want to explore the reasons now or later). Most patients are somewhat embarrassed if they begin to cry and will not continue for long. and don't run out of the room--you want to show that you're willing to deal with anything that comes up." · "Nothing more can be done. (7) .