Dr.

Abdulmoneam Saleh
Family Physician,JBFM,HSFM
Dept. of Family & Community Medicine
University Of Tabuk
Learning Objectives :

 To understand the definition of bad news.

 To understand why this is an important part of

communication skills.

 To become familiar with certain illnesses/ problems

which may require giving bad news.

 To become aware of:

 What to do?
 How to do it?
 What not to do?
 Breaking Bad News
 A difficult but fundamentally important task for all
health care professionals

 Physicians feel uncertain & uncomfortable while

breaking bad news, leading to being distant &
disengaged from their patients.
 Breaking Bad News
 Studies have shown that:
 Patients generally (50-90%) desire full & frank
disclosure, though a sizeable minority still may
not want the full disclosure. (Ley p. Giving
information to patients. New York: Wiley, 1982 )

 Focused training in communication skills &

techniques to facilitate breaking of bad news has
been demonstrated to improve patients
satisfaction & physicians comfort.
 What is bad news?
 “any news that drastically and negatively alters the
patients view towards his future.”
 Buckman R. BMJ1984

 It alters one’s self-image : “I left my house as one

person & came home another.”
 Professional cyclist Lance Armstrong’s recollection
 Examples of Conditions Requiring
Breaking of Bad News

 Cancer related diagnoses

 Intra uterine foetal demise
 Life long illness: Diabetes, Epilepsy
 Poor prognosis related to chronic diseases: loss of
independence
 Informing parents about their child’s serious
mental/physical handicap
 Giving diagnosis of serious sexually transmitted disease
…catastrophic psychosocial results
 Non clinical situations like giving feedback to poorly
performing trainees or colleagues
Barriers to effective disclosure
 It is referred by some physicians like “dropping the bomb”
 Baile W F, oncologist 2000

Common Barriers include

Physician’s fears of :
 Being blamed by patient
 Not knowing all the answers
 Inflicting pain & sufferings
 Own illness & death
 Lack of training
 Lack of time
 Multiple physicians---who should perform the task
 Patient’s perspective
Most important factors for patients include:
 Physician’s competence, honesty & attention
 The time allowed for questions
 Straightforward & understandable diagnosis
 The use of clear language

 Parker PA, Baile WF j.clinical onc 2001

 Family's perspective
Family members prefer:
 privacy
 Good attitude of the person who gives the bad news
 Clarity of message
 Competency of physicians
 Time for questions

 Jurkovich GJ, et al. J Trauma 200

 Delivering Bad News
 “It is not an isolated skill but a particular form of
communication.”
 Frank A. Eur J of Palliat care 1997

 Rabow & Mcphee (West J. Med 1999) described:

“Clinicians focus often on relieving patients’ bodily
pain, less often on their emotional distress & seldom on
their suffering.”
 Delivering Bad News
Rabow & Mcphee (West J. Med 1999) synthesized a
simple mnemonic of ABCDE:
 Advance Preparation
 Build a therapeutic environment/relationship
 Communicate well
 Deal with patient & family reactions
 Encourage and validate emotions
 Advance Preparation
 Familiarize yourself with the relevant clinical
information (investigations, hospital report)

 Arrange for adequate time in private, comfortable

environment

 Instruct staff not to interrupt

 Be prepared to provide at least basic information about

prognosis and treatment options (so do read it up)
 Advance Preparation
 Mentally rehearse how you will deliver the news. You
may wish to practice out loud

 Script specific words & phrases to use or to avoid

 Be prepared emotionally
 Build a therapeutic
environment/relationship

• Introduce yourself to everyone present

• Summarise where things have got to date, check
with patient/relative
• Discover what has happened since last seen
• Judge how the patient is feeling/thinking
• Determine the patient’s preferences for what and
how much he/she wants to know
 Build a therapeutic
environment/relationship (cont.)
 Warning shot “I’m afraid it looks more serious than we
had hoped”
 Use touch where appropriate
 Pay attention to verbal & non verbal cues
 Avoid inappropriate humour
 Assure patient that you will be available
 Communicate well
 Speak frankly but compassionately.
 Avoid medical jargon.
 Allow silence & tears; proceed at patient’s pace.
 Have the patient describe his/her understanding
of the information given.
 Encourage questions.
 Write things down & provide written information.
 Conclude each visit with a summary & follow up
plan.
Deal with patient and family reactions

 Assess & respond to emotional reactions

 Be aware of cognitive coping (denial, blame, guilt,
disbelief, acceptance, intellectualization)
 Allow for “shut down”, when patient turns off &
stops listening
 Be empathetic; it is appropriate to say “I’m sorry or
I don’t know.
 Don’t argue or criticize colleagues
Encourage and validate emotions

 Offer realistic hope.

 Give adequate information to facilitate decision

making.

 Explore what the news means to the patient & inquire

about spiritual needs.

 Inquire about the support systems in place.

Encourage and validate emotions

 Attend to your own needs during and following

the delivery of bad news (counter-transference can
be harmful)

 Use multidisciplinary services to enhance patient

care ( hospice)
 Formal or informal debriefing session with
concerned team members may be appropriate
Six Steps for BBN

Setting up the interview

Perception of the patient for their illness
Invitation from patient to share information
Knowledge and Information conveyed
Emotions responded to empathically
Summary and Strategy for follow-up
BBN:
The “S-P-I-K-E-S” 6 Step Protocol

S Getting the SETTING right

P Assessing what the patient PERCEIVES
I Obtaining an INVITATION to share the news
K Giving the KNOWLEDGE and information
E Addressing the patient’s EMOTIONS
S STRATEGY and SUMMARY
Breaking Bad News
 S - SETTING
 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
Breaking Bad News

 S – SETTING (cont.)
 Lab reports, X-rays present
 Support person present , if desired
 Review the condition, basic prognosis and
treatments before the visit
 Hopeful Tone
Breaking Bad News
 P - Finding out what the patient knows or
PERCEIVES
Before you tell, ask ……
What do they Know?
e.g. “what have you been told so far?”
How much do you understand about your
illness? . How do you feel?
What is troubling you the most?
Note denial (if present) or misinformation
Breaking Bad News
 I - INVITATION by the patient to share the
information
 From the patient to give the information. Would
you like me to explain ……..? Are you the
sort of person who wants to know what’s
happening?
Different ways of asking
e.g. “Are you the sort of person who...”
Accept their right not to know
Aim to get clear invitation
Breaking Bad News
 K - Giving the KNOWLEDGE and medical facts

 Giving information
 Warning shots
 Small chunks
 Check understanding
Breaking Bad News
Emotions
 Observe for and allow emotional reactions
 Kleenex handy, use of touch

Naming the feeling “I know this is upsetting”

Understanding “It would be for anyone”
Respecting “You’re asking all the right questions”
Supporting “I’ll do everything I can to help you
through this.”

Summarise & Strategy

 Have a plan
Breaking Bad News
Emotions
 Observe for and allow emotional reactions
 Kleenex handy, use of touch

Naming the feeling “I know this is upsetting”

Understanding “It would be for anyone”
Respecting “You’re asking all the right questions”
Supporting “I’ll do everything I can to help you
through this.”

Summarise & Strategy

 Have a plan
. Summary and Strategy
for follow-up

 Summarize discussion
 Clear follow-up plan : referral, tests, next contact
(in <48 hrs.)
 Provide written summary or brochures
 Refer to community resources
 Invite support person for next visit if not present
Summary and Strategy
for follow-up

 End on note of hope and partnership

 AFTER: document well
assess your own reaction
 What to do?
 Introduce yourself
 Look to comfort and privacy
 Determine what the patient already knows
 Warn the patient that bad news is coming
 Break the Bad News
 Determine what the patient wants to know
 Identify the patient’s main concern
 Summarize and check understanding
 Offer realistic hope
 Arrange follow up and make sure that some one is with
the patient when he leaves
How to do it ?
 Be sensitive
 Be empathic and consider appropriate touching
 Maintain eye contact
 Give information in small chunks
 Repeat and clarify
 Regularly check understanding
 Do not be afraid of silence or tears
 Explore patient’s emotions and give him time to
respond
 Be honest if you are unsure about something
What not to do ?
 Hurry
 Give all the information in one go
 Give too much information
 Use medical jargon or unclear language/words
 Lie or be economical with the truth
 Be blunt. Words can be like loaded pistols/guns
 Guess the prognosis (She has got 6 months, may be 7)
Quotation
 The greatest revolution of our generation is the
discovery that human beings, by changing the
inner attitudes of their minds , can change the
outer aspects of their lives.
William James
American Psychologist & Philosopher
Thank You