Breaking The Breaking The Bad NewsBad News

BrigBrig

Khalid Hayat KhanKhalid Hayat Khan

Classified PsychiatristClassified Psychiatrist

AFIMH RawalpindiAFIMH Rawalpindi

Breaking the Bad NewsBreaking the Bad News

There are many real life situations where There are many real life situations where bad news has to be communicated to the bad news has to be communicated to the patient, their relatives and/or even to patient, their relatives and/or even to those you even don’t know. For e.g. those you even don’t know. For e.g.

• Disclosing the diagnosis of incurable or dreadful Disclosing the diagnosis of incurable or dreadful diseases like cancers, AIDS, ischaemic heart diseases like cancers, AIDS, ischaemic heart disease etc.disease etc.

• Disclosing still birth of the baby to mother.Disclosing still birth of the baby to mother.• Disclosing death of a loved one.Disclosing death of a loved one.• Disclosing massive financial loss, property lossDisclosing massive financial loss, property loss. .

Breaking the Bad NewsBreaking the Bad News

Breaking the bad news is an unpleasant Breaking the bad news is an unpleasant task and can be learned from the senior task and can be learned from the senior physicians or through own professional physicians or through own professional experience.experience.

There are five schools of thought There are five schools of thought regarding breaking the bad news.regarding breaking the bad news.

• The biopsychosocial (BPS) modelThe biopsychosocial (BPS) model• Individualized disclosure modelIndividualized disclosure model• Full disclosure modelFull disclosure model• Paternalistic disclosure model Paternalistic disclosure model • Non disclosure model Non disclosure model

BPS ModelBPS Model

It provides a clear, crisp, evidence based It provides a clear, crisp, evidence based information on the patient’s condition but information on the patient’s condition but tailors the flow and amount of information tailors the flow and amount of information according to the needs of the patient.according to the needs of the patient.

A vertical flow of all data on the disease is A vertical flow of all data on the disease is avoided. The bad news is broken using the avoided. The bad news is broken using the principles of effective communication, principles of effective communication, counseling and informational care. The counseling and informational care. The patient is encouraged to involve his family patient is encouraged to involve his family members, as a part of psychosocial support, members, as a part of psychosocial support, during the session as well as in the long run. during the session as well as in the long run.

BPS ModelBPS Model

It is the best model to be recommended for It is the best model to be recommended for use in health settings.use in health settings.

This model suggests the following steps for This model suggests the following steps for a session that aims at breaking a bad news:a session that aims at breaking a bad news:

Step 1: Seating and Setting (Environment)Step 1: Seating and Setting (Environment)

ExclusivityExclusivity: : A private room where doctor A private room where doctor and patient can focus on the subject and patient can focus on the subject attentively.attentively.

BPS ModelBPS Model

Involvement of significant othersInvolvement of significant others: : This gives This gives patient psychosocial support and alleviates patient psychosocial support and alleviates some stress from the doctor in the face of an some stress from the doctor in the face of an emotionally charged interview.emotionally charged interview.

Seating arrangementsSeating arrangements: : The doctor and the The doctor and the patient should be comfortably and patient should be comfortably and respectfully seated next to each other, respectfully seated next to each other, preferably at a distance of an arms lengthpreferably at a distance of an arms length

Be attentive and calm; maintain eye contactBe attentive and calm; maintain eye contact:: Care about patient’s feelings if he weeps Care about patient’s feelings if he weeps

during the interview:during the interview:

BPS ModelBPS Model

Listening modeListening mode: : Silence and repetition of last Silence and repetition of last few words that the patient has said, are two few words that the patient has said, are two communication skills that will send across the communication skills that will send across the message that you are listening well.message that you are listening well.

Step 2: Patient’s perceptionStep 2: Patient’s perception

Before breaking bad news, try to ascertain as Before breaking bad news, try to ascertain as accurately as possible, the patient’s perception accurately as possible, the patient’s perception of his or her medical condition. If the patient is of his or her medical condition. If the patient is in in

BPS ModelBPS Model

denial, try not to confront him in the first denial, try not to confront him in the first interview, as denial is an unconscious defense interview, as denial is an unconscious defense mechanism that facilitates coping.mechanism that facilitates coping.

Step 3: InvitationStep 3: Invitation

Although most patients want to know all about Although most patients want to know all about their illness but assumption towards that their illness but assumption towards that should be avoided. Obtaining overt permission should be avoided. Obtaining overt permission respects the patient’s right to know or not to respects the patient’s right to know or not to know.know.

BPS ModelBPS Model

Some examples to address this are:Some examples to address this are:

• ““Are you the kind of person who likes to know Are you the kind of person who likes to know all the details about what’s going on?”all the details about what’s going on?”

• ““How much information would you like me to How much information would you like me to give you about your diagnosis and treatment?” give you about your diagnosis and treatment?”

• “ “ Would you like me to give your details about Would you like me to give your details about what is going on or would you prefer to know what is going on or would you prefer to know about the treatments I am prescribing to you?”about the treatments I am prescribing to you?”

BPS ModelBPS Model

Step 4: KnowledgeStep 4: Knowledge

Before breaking the bad news, give your Before breaking the bad news, give your patient a warning of some sort to help him patient a warning of some sort to help him prepare for himself e.g.prepare for himself e.g.

• ““Unfortunately I have some bad news to tell Unfortunately I have some bad news to tell you Mr . X……….”you Mr . X……….”

• “ “ I am sorry to tell you Mr. X that………”I am sorry to tell you Mr. X that………”• “ “ Mr. X every human being in this world Mr. X every human being in this world

faces ups and downs in his or her life, do youfaces ups and downs in his or her life, do you

BPS ModelBPS Model

agree with it ?…………”agree with it ?…………”• ““The life is such that every one of us has to The life is such that every one of us has to

come across some bad event/news which come across some bad event/news which one has to bear with courage……….”one has to bear with courage……….”

• “ “ Mr. X how are you going to respond to the Mr. X how are you going to respond to the scenario of a person, that I am going to put scenario of a person, that I am going to put in front of you, who has suddenly lost one of in front of you, who has suddenly lost one of his son in earthquake disaster……….” his son in earthquake disaster……….”

BPS ModelBPS Model

Step 5: EmpathyStep 5: Empathy

Show Show empathic response empathic response to the patient. In to the patient. In empathic response one needs to listen and empathic response one needs to listen and identify the emotion (or mixture of identify the emotion (or mixture of emotions) that the patient is experiencing emotions) that the patient is experiencing and acknowledge them. Validate patient’s and acknowledge them. Validate patient’s feelings, reassure him that you understand feelings, reassure him that you understand the human side of the medical issue and the human side of the medical issue and that you have a respect for his feelings. that you have a respect for his feelings.

BPS ModelBPS Model

Step 6: SummarizeStep 6: Summarize

Before the discussion ends, recapitulate Before the discussion ends, recapitulate the information in a short summary of all the information in a short summary of all that has been discussed and give your that has been discussed and give your patient an opportunity to voice any major patient an opportunity to voice any major concerns or questions.concerns or questions.

BPS ModelBPS Model

Step 7: Plan of ActionStep 7: Plan of Action

You and your patient should go away from You and your patient should go away from the interview with a clear plan for the next the interview with a clear plan for the next steps that need to be taken and the role steps that need to be taken and the role you both would play, in the management you both would play, in the management of the issues.of the issues.

Individualized Individualized Disclosure ModelDisclosure Model

The amount of information disclosed and the rate The amount of information disclosed and the rate of its disclosure are tailored to the individual of its disclosure are tailored to the individual patient by doctor-patient negotiation.patient by doctor-patient negotiation.

The underlying assumptions in this model are The underlying assumptions in this model are that people are different, it takes time to absorb that people are different, it takes time to absorb and adjust to bad news and a partnership and adjust to bad news and a partnership between doctor and the patient for decision between doctor and the patient for decision making is in the patient’s best interest.making is in the patient’s best interest.

The distinguishing feature of this model are that The distinguishing feature of this model are that it takes time and skills which the busy physician it takes time and skills which the busy physician

Individualized Individualized Disclosure ModelDisclosure Model

may feel that he or she does not have.may feel that he or she does not have. The The advantagesadvantages are that the amount of are that the amount of

information given and rate of disclosure is information given and rate of disclosure is tailored to the needs of individual and a tailored to the needs of individual and a supportive relationship with the doctor is supportive relationship with the doctor is established.established.

The The disadvantagesdisadvantages are that it is a very time are that it is a very time consuming process, requires skills and it consuming process, requires skills and it drains a caregiver’s emotional resources.drains a caregiver’s emotional resources.

Full Disclosure ModelFull Disclosure Model

This model involves giving full information to This model involves giving full information to the patient with the underlying assumptions the patient with the underlying assumptions that the patient has a right to full information that the patient has a right to full information about himself and the doctor has an obligation about himself and the doctor has an obligation to give it; patient himself should decide what to give it; patient himself should decide what treatment is best for him. treatment is best for him.

The The advantagesadvantages are that it promotes doctor- are that it promotes doctor-patient trust and communication; and patient trust and communication; and facilitates mutual support within the family facilitates mutual support within the family unit.unit.

Full Disclosure ModelFull Disclosure Model

The The disadvantagesdisadvantages are that the discussion are that the discussion of options in detail may frighten and of options in detail may frighten and confuse some patients; insisting on confuse some patients; insisting on information may undermine defenses e.g. information may undermine defenses e.g. denial, which are otherwise important for denial, which are otherwise important for the survival of the patient; and lastly full the survival of the patient; and lastly full information may have negative emotional information may have negative emotional consequences for some.consequences for some.

Paternalistic Paternalistic Disclosure ModelDisclosure Model

This model implies that the information This model implies that the information about patient’s disease is the right of the about patient’s disease is the right of the doctor and he delivers the information in a doctor and he delivers the information in a “sugar coating” “sugar coating” to minimize the pain and to minimize the pain and distress of the patient.distress of the patient.

It also involves the expression of sympathy It also involves the expression of sympathy and a sharing of emotions on the part of and a sharing of emotions on the part of the doctor.the doctor.

This model is not a recommended method This model is not a recommended method any more. any more.

Non Disclosure ModelNon Disclosure Model

This model is based on the view that under This model is based on the view that under no circumstances should patients be no circumstances should patients be informed that they have acquired a lethal informed that they have acquired a lethal disease, and that deception should be used if disease, and that deception should be used if necessary, on the basis that the patient necessary, on the basis that the patient needs protection from the terrible reality of needs protection from the terrible reality of terminal illness.terminal illness.

The The advantagesadvantages of this model are that it is of this model are that it is easier, less time consuming for the doctor easier, less time consuming for the doctor and suits those people who prefer not to and suits those people who prefer not to know their condition.know their condition.

Non Disclosure ModelNon Disclosure Model

The disadvantages are that the trust in The disadvantages are that the trust in doctor is undermined; opportunities for doctor is undermined; opportunities for helpful interventions are lost; patient’s helpful interventions are lost; patient’s compliance is less likely; patient may compliance is less likely; patient may acquire wrong information from anybody acquire wrong information from anybody that can lead to avoidance, isolation and a that can lead to avoidance, isolation and a perceived sense of rejection.perceived sense of rejection.

This model is out of favour and is widely This model is out of favour and is widely rejected by modern day doctors as well as rejected by modern day doctors as well as patients and their families.patients and their families.

THANK YOUTHANK YOU