Why is it so hard to break bad news?
- Not understanding what bad news is
- Fear of how the patient will react
- A sense of failure or guilt
Breaking bad news using Neighbour's 5-stage model of the consultation
Step 1: Connect
Try to see the world through the patient's eyes, and discover his agenda or priorities.
Useful phrases include
- How are you getting on?
- What did they tell you at the hospital?
- Is there anything you want to know about your tests/illness/operation?
Be alert for unspoken as well as spoken answers. Feelings perceptible at the edge of the discussion will probably indicate the the real state of affairs better than the facts actually discussed.
Step 2: Summarise
Reflect back to the patient the impression that you have gained of the situation. This shows that you have understood his/her feelings and gives the patient a chance to correct, refine and expand on them.
Step 3: Hand over
If you answer the questions to the best of your ability and admit any uncertainties, the knowledge that forms bad news is handed over in a way that empowers the patient to keep control of his/her life. To withhold information is also to withhold control and demeans the patient.
Step 4: Safety net
Safety netting is the doctor checking where the patient is, often acknowledging his/her pain, grief or bewilderment - "this must come as an awful shock to you". It is recognising the feelings that lie behind the stunned silence.
If you recognise a grief reaction, in particular the various emotional components of fear, anxiety, denial and so on, this can provide valuable insight into how much further information the patient wants and in what way it can be usefully expressed. If the patient's feelings are "allowed", he/she is more likely to pass through them and acheive some acceptance of the situation.
Give the patient the opportunity to ask for further help. Initially, the patient may be too bewildered to take anything further and should not be swamped with too many details. So leave the door open for further discussion.
Step 5: Housekeeping
The doctor reviews his/her own feelings. Dealing with death or dying is a major cause of stress for medical staff. Never has a patient complained because a doctor shed a tear with him: it seems that patients gain support in dealing with bad news when they perceive their informant is also distressed.
The professional dictum of "not to get involved" has encouraged emotional supression within the profession that prevents the doctor showing distress.
Areas to discuss
- Checking awareness
- Giving bad news
- Managing distress
- Exploring concerns
- Handling uncertainty
- Difficult questions
- Handling denial
- Is collusion a coping mechanism that is acceptable?
- Dealing with anger
Doctor: Warning shot I'm afraid the news isn't very good. Patient: What do you mean? Doctor: Staging The bone marrow is not making the right type of blood cells. Patient remains silent but looks at doctor enquiringly. Doctor: Staging There are underlying problems with the bone marrow Patient: So what is it? Doctor: Breaking the bad news It's a type of leukaemia.
Points in breaking bad news
- Know the personal details of the patient.
- Have all the information readily available.
- Prepare yourself for what you will say.
- Have someone else present if necessary - if possible, someone who has had prior contact with patient, or a relative/friend. Assess/ask who they would like to have with them.
- Introduce yourself properly.
- Spend a few minutes establishing rapport.
- Ask for information from the recipient to establish their knowledge of the situation.
- Speak clearly, using non-medical terminology.
- Write down any technical terms if necessary.
- Find out patient's views.
- Assess the patient's understanding of the diagnosis.
Pacing and shared control
- Allow for pauses - silences are useful.
- Try to lead the patient towards making the diagnosis.
- Let the patient take some of the lead - involve them in the management decisions.
- Allow them to ask questions.
Responding to emotions
- Touch the patient/relative if appropriate.
- Reassure them that is alright for them to cry. Allow expression of emotion.
- Eye contact and non-verbal communication.
- Show your own emotion.
- Offer both worst and best scenarios.
- If appropriate, leave the recipient of the news with some hope.
- Take responsibility for any mistakes and apologise.
- Do not be afraid to say things like "sorry" and "I don't know" - more useful to be honest if you do not have the full clinical knowledge.
- Highlight any positive help eg pain relief.
- Offer continuing support/ practical advice.
- Have a plan for the future - help the patient/relative to plan.
- Summarise at the end of the discussion/.
- Finish with any positive points.
- Close discussion by inviting questions.
- Make sure the patient can get home OK.
- Set the next meeting.
- Give a telephone number.
- Medical education 1995,29,430-435.
- Update July 1996
- Breaking bad news - BMJ