BREAKING BAD NEWS

Dr Giftie Ajayi P.
Registrar Family Medicine
ABUAD Multisystem Hospital
01/09/2022
 Outline
• OBJECTIVES
• INTRODUCTION
• DEFINITION
• WHAT MAKES IT DIFFCULT?
• WHY SHOULD IT BE DONE?
• STRATEGIES FOR BREAKING BAD NEWS
• WORDS TO AVOID
• ROLE OF THE FAMILY PHYSICIAN AS APPLIED TO BREAKING BAD
NEWS
• CONCLUSION
• REFERENCES
 OBJECTIVES
• To understand what constitutes a bad news
• To identify obstacles to communication of bad
news
• To discuss some strategies for breaking bad
news in medical practice
• To be able to use an organized approach in the
communication of bad news.
 INTRODUCTION
• Breaking bad news to patients has been a subject
of professional concern for many years, interest
growing alongside a culture of increasing medical
disclosure and prognosis [Buckman, 1992]
• The life of a sick person can be shortened not only
by the act but also by the words or the manner of
a physician. It is, therefore, a sacred duty to guard
himself carefully in this respect, and to avoid all
things which have a tendency to discourage the
patient and to depress his spirits [American
medical association].
 INTRODUCTION
• Breaking bad news demands a great deal of
professionalism, patience, and energy. It
requires the complex processes of finding:
• Appropriate kind words and understandable
terminology
• The secondary task of assessing how the
patient and family are reacting
• The degree of distress that the conversation is
inducing.
 INTRODUCTION
• Studies show that discussions of bad news do
not meet patients needs and fall short of expert
recommendations
• Patients with cancer tend to disclose fewer than
50% of their concerns because of inability to
communicate with their physician
• Patients generally (50-90%) desire full and frank
disclosure; though a sizeable minority still may
not want the disclosure.
 WHAT IS A BAD NEWS?

‘I left my house on Oct. 2 1996 as one person

and came home another’

-Lance Amstrong’s recollection of being

diagnosed with Testicular Cancer.
 DEFINITION
• Bad news is “any news that drastically and
negatively alters the patient’s view of his or
her future and result in persistent cognitive,
and behavioural, and emotional responses.”
(R. Buckman)
• It can also be seen as diagnosis that comes at
an inopportune time.
 DEFINITION
• A situation where there is either a feeling of
no hope, a threat to one’s mental or physical
well-being, a risk of upsetting an established
lifestyle, or where the message given conveys
fewer choices in his or her life.
• SLAI- Sharing life altering information
• It can be seen as the gap between the patients
expectations and the reality of the patients medical
condition E.g.
• News of a degenerative disorder (Parkinson’s disease),
cancer, metabolic diseases
• Intrauterine fetal demise
• Failure of medications, radiotherapy or poor prognosis e.g
metastasis, resistance or a relapse etc
• News that threatens a patients means of livelihood e.g
amputation of limb of an athlete or surgeon
• Medical error to patient and family members
• Diagnosis of serious sexually transmitted disease such as
HIV
 WHAT MAKES IT DIFFICULT?
The physician’s perspective
• Uncertainty about the patient’s condition &
expectations
• Fear of destroying the patient’s hope
• Fear of their inadequacy in the face of an uncontrollable
disease
• Fear of patient’s anticipated emotional reactions
• Embarrassment at having previously painted too
optimistic a picture for the patient
• Cultural constraints and language barriers
• Lack of training in breaking bad news
 WHAT MAKES IT DIFFICULT?
The patient’s perspective
• Patient often have vivid memories of receiving
bad news
• Negative experiences can have lasting effects
for example depression
• Fears of social stigma and impact of disability
and illness.
 WHY SHOULD IT BE DONE?
• Improve the patient’s and family’s ability to
plan and cope
• Encourage realistic goals and autonomy
• Strengthen the doctor-patient relationship
• Facilitates open discussions among patient,
relatives and doctors
• Empowers patient by allowing them have a
greater say in treatment
STRATEGIES FOR BREAKING BAD NEWS

• Different strategies have been applied by

doctors and these includes:
1. ABCDE
2. SPIKES
3. BREAKS
4. CONES
• SPIKES AND ABCDE appear to be the most
commonly used.
 ABCDE strategy
• A= Advanced preparation
• B= Build a therapeutic environment/
relationship
• C= Communicate well
• D= Deal with patients and family reactions
• E= Encourage and validate emotions
 A - Advanced preparation
• Familiarize yourself with the relevant clinical
information e.g investigations, hospital report etc
• Arrange for adequate time and privacy,
comfortable environment
• Instruct staff not to interrupt
• Be prepared to provide at least basic information
about progress and treatment options (read it up if
need be)
• Mentally rehearse how you will deliver news
• Script specific words and phrases to use or to avoid
 B - Build A Therapeutic
Environment/Relationship
• Introduce yourself to the patient and
everyone present
• Determine patient preferences for what and
how much they want to know
• Summarize what has happened to date.
• Give a warning shot “I am afraid it looks more
serious than we had hoped it would be”
• Use touch when appropriate
 B - Build A Therapeutic
Environment/Relationship
• Pay attention to verbal and non verbal cues
• Avoid inappropriate humor
• Assure patient that you will be available
 C - Communicate Well
• Speak frankly but compassionately
• Determine the patients knowledge and understanding
of the situation
• Proceed at the patients pace
• Avoid medical jargons
• Allow for silence and tears
• Have patient describe his/her understanding of the
information given
• Encourage and answer questions
• Provide written/ drawn information to encourage
understanding and remembrance
D - Deal with Patient and Family Reactions

• Assess and respond to emotional reactions

• Be empathetic
• Be aware of cognitive coping strategies e.g
1. Denial
2. Blame
3. Disbelief
4. Intellectualization
5. Acceptance
D - Deal with Patient and Family Reactions

• Assess for despondency and suicidal ideations

• Allow for “shut down” when patients turn off
and stops listening
• Don’t argue with or criticize colleagues. Avoid
defensiveness regarding your, or a colleague’s,
medical care.
 E - Encourage and Validate Emotions
• Offer realistic hopes and encouragement about
what options are available
• Explore what the bad news means to the patient
• Discuss treatment options
• Use interdisciplinary services to enhance patient
care (e.g., hospice), but avoid using these as a
means of disengaging from the relationship.
• Attend to your own needs during and following
the delivery of bad news.
 SPIKES PROTOCOL
• The SPIKES protocol was developed by the late
Robert F Buckman, Walter F Baile and their
colleagues in 1992.
• It provides a step-wise framework for difficult
discussions such as when cancer recurs or
when palliative or hospice care is indicated.
 SPIKES PROTOCOL
S– Setting up the interview
P– Perception
I– Invitation (involving the patient)
K– Knowledge to the patient
E– Emotions and Empathy
S– Strategy and Summary
 SETTING 1
• PRIVACY- find a private location such as an interview
room, your office with the door closed or curtains
drawn around a bed
• Ask the patients permission to turn off the TV or the
radio to minimize distraction
• INVOLVE SIGNIFICANT OTHERS
• Some patients may or may not like to have family
members or friends around with them
• If there are a number of people closely supporting the
patient ask your patient who will act as a
spokesperson for everybody during the discussion
 SETTING 2
• SIT DOWN
• You have to be seated during an interview to break
bad news
• Avoid sitting behind barriers
• If the patient is in a hospital bed pull up a chair or if
there is no sit ask for permission to sit on the edge
of the bed
• Being seated lessons the intimidating visual impact
of the doctor towering over the patient, which can
make a patient feel uncomfortable
 SETTING 3
• LOOK ATTENTIVE AND CALM
• Maintain eye contact, this assures patient that you
are listening
• If you are fidgety, you can adopt the “psychotherapy
neutral position”. This involves placing your feet flat
on the floor and your ankles together and putting
your hands, palms downward on your lap.
• If the patient becomes tearful, you can break eye
contact momentarily
 SETTING 4
• AVAILABILITY
• Make arrangement for the phones to be answered
by other staff members or voice mail.
• Make sure staff members do not interrupt the
meeting.
• If however unavoidable phone calls or
interrupting do occur, courteously address them
so that your patient doesn’t feel less important.
 PERCEPTION 1
• Assess the patients understanding or the seriousness of
their condition.
• Ask what the patient and family already know
• “Tell me what you understand about your condition so
far”
• “What did you think was going on with you when you felt
the lump?”
• Assess the patient and family members level of
understanding
• Take note of discrepancies in the patient’s understanding
and what is actually true. Correct misinformation.
 PERCEPTION 2
• Watch for signs of denial. It is often helpful not
to confront the denial at the first interview.
Denial is an unconscious mechanism that may
facilitate coping and should be treated gently
over subsequent interviews (if time permits)
• Confrontation of denial outrightly may raise
anxiety unnecessarily or even set up an
adversarial or antagonistic relationship
 INVITATION
• Determine how much information and detail a
patient desires
• Ask permission to give results so that the patient
can control the conversation.
• “How much information would you like me to
give you about your diagnosis and treatment?’’
• ‘’Would you like me to give you details of what is
going on or would you prefer that I just tell you
about the treatment I am proposing?’’.
• Offer to answer any questions the patient/family
members may have.
 K– KNOWLEDGE 1
• Before you break bad news, give your patient
a warning that bad news is coming.
• This gives your patient a few seconds longer to
prepare psychologically for the bad news e.g
• “Unfortunately, I’ve got some bad news to tell
you”
• “It looks like the result is not very good”
• Avoid technical scientific language as much as
possible e.g instead of metastasized- say
“spread”
 KNOWLEDGE 2
• Stop often to confirm understanding
• ‘‘I know this is a lot of information, what
questions do you have so far?’’
• Avoid being pessimistic, over optimistic but
tell the whole truth.
 E- EMPATHY AND EMOTION
• Acknowledge patients emotions as they arise and address
them.
• ‘’I can see this is not the news you were expecting.’’
• Use empathic statements to recognize the patient’s
emotion
• ‘’Yes, I can understand why you felt that way.’’
• Validate responses to help the patient realize his or her
feelings are important.
• ‘’Could you tell me more about what concerns you?’’
• Ask exploratory questions to help understand when the
emotions are not clear.
 TYPES OF EMPATHIC EXPRESSION

NON VERBAL EXPRESSION OF EMPATHY

• Maintain eye contact
• Sit down close to and face the patient
• Have an open body posture, with no obstacles
between you and the patient
• Touch (be mindful to touch neutral parts of
the body e.g arms)
 TYPES OF EMPATHIC EXPRESSION
VERBAL EXPRESSION OF EMPATHY (the “NURSE” acronym)
N- Name the emotion (‘’You seem angry’’)
U- Understand/normalize the emotion (‘’This must be hard
and difficult’’)
R- Respect the patient and family for how they are
coping(‘’I’m impressed with how well you have handled
the treatment’’)
S- Support the patient so they don’t feel alone (‘’Our team
will be here’’)
E- Explore the emotion further, (‘’Tell me more about why
you feel this way”)
 S-- STRATEGY AND SUMMARY
• Summarize the news to facilitate understanding
• Decide what the best medical plan would be for the
patient
• Possibly have a clear treatment plan in writing for
the patient to take home with him
• Set a plan for follow- up (referrals, further tests)
• Ask the patient to repeat to you their understading
of the plan
• Offer a means of contact if additonal questions arise.
• Offer to answer questions (be prepared for tough
questions)
 BREAKS
• Put together by Drs Narayanam, Bista, Koshy all from India
• B- Background- In depths knowledge of the patients problem
• R- Rapport – The physician should establish a good rapport with
the patient
• E- Exploring- Find out what patient knows about the illness,
identify potential conflicts between the patients belief and the
diagnosis, if patient allows you, involve significant others.
• A- Announce- Give a warning, short information should be
given in easily comprehensive sentences, a useful rule of thumb
is not to give more than three pieces of information at a time.
• K- Kindling- Observe patient’s response, his or her emotional
reaction and kindle the emotion.
• S- Summarize – Summarize just as in the SPIKES strategy
 THE CONE PROTOCOL
Used in the following situations
1. Disclosing a medical error
2. Sudden deterioration in the patients medical condition
3. Sudden unexpected death
• Note:
• The news should be delivered by the most senior person on the
patients treatment team.
• C- Context
• O- Opening slot
• N- Narrative
• E- Emotions
 C- Context
• Prepare for what to say and anticipate the patient family
reaction
• Have the conversation in a quiet undisturbed area
• Seat the patient closest to you and have no barriers between
you
• Have a box of tissues available.
O- OPENING SLOT
• Alert the patient/ family members of the impending bad
news
• “This is difficult, I have to tell you what I found out about
why your mother is so ill”
• “I must talk to you about your condition”
 N- NARRATIVE APPROACH
Explain the chronological sequence of events
• Avoid assigning blame and or making excuses
• Emphasize that you are investigating how the error occurred
• OFFER A CLEAR APOLOGY

E- EMOTIONS
• Address strong emotions with emphatic responses
• Use the E– V– E protocol as soon as emotions occurs
• (EXPLORE, VALIDATE, EMPHATHIZE)
• “It’s very rare, but it does happen and I am sorry to say that it
did”
• Beware of being pushed into making promises you can’t deliver
• Avoid reassuring the person that there is going to be a good
outcome or that no harm was done.
 OBSTACLES TO COMMUNICATION OF BAD
NEWS
• Medical education doesn’t teach it well enough
• Cultural differences in disclosure of information
• Time limitations of medical staff
• Some doctors feel it is a waste of their precious time
so they spend little time as possible doing it
• Mutiple physicians- who should perform the task
• Fear of the medico-legal system
• Some families don’t want the patient to know the
whole truth about his/her health
 WORDS TO AVOID IN BBN
• ‘’I can’t care for you anymore’’
• ‘’There is no more hope’’
• ‘’It is time for us to stop treatment’’
• ‘’There is nothing more we can do for you’’
• Instead of saying ‘’I am sorry’’ you may say ‘’I
wish things were different.’’
• Do not say ‘’We are going to stop the machine
or pull the plug’’
 THE ROLE OF THE FAMILY PHYSICIAN

• The family physician is a six star physician

playing the role of the patients:
• 1. Care giver
• 2. Coordinator
• 3. Communicator
• 4. Advocate
• 5. Resource manager
• 6. Researcher
• The family physician is the first contact person serving
as port of entry into the health care system and
committed to patient centered comprehensive care
• He or she serves a coordinative function for the patient
by involving relevant medical/paramedical colleagues
to help patient deal with patients medical issues
• Coordinates referrals and translates special advice and
feedback
• The family physician uses every opportunity for health
promotion, preventive care, patient education and
rehabilitation.
• Explores the FEARS, IDEAS, EFFECT ON
FUNCTION, AND EXPECTATIONS of the patient
(FIFE)
• He or she is the advocate 1)defining what is
needed to help patient with due regard to cost
effectiveness 2) assessment of impact of
health condition on the family 3)identifying
with values and beliefs of the patient.
• He is the resource manager helping in the
Human. Financial , Material, Time
management (the 4 M’s)
• Involvement in ongoing research bringing
interesting or new findings to the lime light.
Research continues in the area of breaking of
bad news, effects on families and the doctor.
 Conclusion
• Breaking bad news is frequently a tense and distressing
experience for both the patient and the physician
• Following an established protocol while integrating
empathetic communication makes the difficult task of
breaking bad news more comfortable for the FP and
helps improve the communication between the patient
and family.
• These skills can be learned in continuing education
programs or easily integrated into the family practice
curriculum.
An expert in breaking bad news is not
someone who gets it right every time, he or
she is merely someone who gets it wrong less
often and who is less flustered when things do
not go smoothly

-R. BUCKMAN
 REFERENCES
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curative to paliiative cancer care- patient’s view of the doctor giving the information.
Support care cancer 2000: 8(6) : 472- 478
• Breaking bad news, American Academy of Family Physicians
• Maguire P. Improving communication with cancer patients Eur J cancer 1999 ; 35 (10) ;
1415- 1422
• Heaven CM, Maguire P. Disclosure of concerns by hospice patients and their identification
by nurses palliat Med 1997 ; (4) 284- 290
• Heaven CM, Maguire P. The relationship between patient concerns and psychological
distress in a hospice setting. Psychooncology 1998; 7 (6) 502 – 507
• Parie M, Jones B, Maguire P. maladaptive coping and affective disorders among cancer
patients psychol Med 1996; 26(4) 735- 744
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