Tips for Bad News Bearers
A Critical Clinical Skill
What is Bad News? Any news that
seriously and negatively alters the patient’s view of his or her future.
Buckman
The GoalHelp the patient and family
understand the condition Support the patient and familyMinimize the risk of overwhelming
distress or prolonged denial
Why is it a critical skill?The Patient’s Perspective
Patients often have vivid memories of receiving bad news
Negative experiences can have lasting effects on anxiety and depression
Can facilitate adaptation to illness and deepen the patient-doctor relationship
Why is it a critical skill?The Physician’s Perspective
High degree of difficulty + Physician anxiety =
High risk of performing poorly
What do patients want?For themselves…more time to talk and show feelings
From the doctor…more information, caring, hopefulness, confidencea familiar face Strauss 1995
What do you do?
What have you have found helpful in making “bad news” visits go as well as possible?
S etting up the interview
P erception of the patient re their illness
I nvitation from patient to share info
K nowledge and Information conveyed
E motions responded to empathically
S ummary and Strategy for follow-up
1. Setting up the interview
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
1. Setting up the interview
Lab reports, X-rays present Support person present , if desired Review the condition, basic
prognosis and treatments before the visit
HOPEFUL TONE
Assessing the patient’s 2. PerceptionASK then TELLImportant if the patient is not well known to
you OR if visits to consultants have occurred
“Assess the Gap” between what the patient knows and the diagnosis
“What have you already been told about might be going on?
“What is your understanding of why the investigation was ordered?”
Obtaining the patient’s3. Invitation Preferably before the visitEasier if patient is well- knownListen to patient cues“Are you the sort of person who likes to
know all the details of your condition?“Would you like me to discuss the results
of the investigations with you?”
Giving 4. Knowledge and Information
Align yourself with the patient’s understanding and vocabulary
Start with a warning shot: “I’m afraid that the scan shows that the problem is fairly serious.”
Give diagnosis simply, avoid euphemisms or excessive bluntness
Provide information in small chunksCheck frequently for understanding
Giving 4. Knowledge and Information
Check for knowledge or experience with condition
Allow for pauses, use repetitionWill usually want basic but clear
information re treatment plan and prognosis
BUTTune into patient readiness to hear
more, and know when to stop
Balancing Truth and Hope: The Skillful Use of Indirect Language S Healing et al 2006
“It looks like….” not “You have….”“there are tumours in the liver…” not
“you have tumours in your liver…”
Emphasize on maintaining the relationship as well as communicating the news
Respond to 5. Emotions empathically
Observe for and allow emotional reactionsKleenex handy, use of touch
N aming the feeling “I know this is upsetting” U nderstanding “It would be for anyone” R especting “You’re asking all the right
questions” S upporting “I’ll do everything I can to help you
through this.”
6. Summary and Strategy for follow-up
Summarize discussionClear follow-up plan re: referral, tests,
next contact (in <48 hrs)Provide written summary or brochuresRefer to community resourcesInvite support person for next visit if
not present
6. Summary and Strategy for follow-up
End on note of hope and partnership AFTER: document well assess your own reaction
Six Steps for Breaking Bad News
S etting up the interview P erception of the patient re their illness I nvitation from patient to share info K nowledge and Information conveyed E motions responded to empathically S ummary and Strategy for follow-up
Discrepancies in Ratings
Patients rated the following much higher than doctor and nurses:
receiving bad news in a quiet, private placearranging a follow-up visit soon to review
with patient and familyinform patient about support services Girgis, Behavioural Medicine 1999
Follow-upPlease take a handout outlining the
SPIKES steps in sharing bad news
Try out one or two of the suggestions next time you have bad news to share
Remember
“The task of breaking bad news is a testing ground for the entire range of our professional skills and abilities. If we do it badly, the patients or family members may never forgive us; if we do it well, they will never forget us.”
Robert Buckman
Thank you!