Breaking Bad News
DR KATHERINE MILES
Learning Objectives
Breaking bad news in the context of ethical principles
Principles of breaking bad news – the SPIKES tool
Consultation skills in breaking bad news
Current Jordanian research on breaking bad news and doctor’s
learning needs
Introducing the concept of palliative care
Case based discussion
What is Bad News?
Serious or life threatening diagnosis e.g. cancer, lifelong diagnosis or
chronic disease – heart failure
Social taboo e.g. HIV infection or epilepsy
Disease or illness that may affect fertility
Different people have different views about what is “bad news”
Terminology changing from “breaking bad news” to “sharing difficult
news”
Reminder of Ethical Principles
Patient autonomy (patient choice on receiving information)
Patient consent (regarding their information and sharing of it)
Patient confidentiality (right to privacy and choosing who they share
their information with: doctor bound by patient confidentiality)
Non-maleficence (do no harm to your patient)
Beneficence (do good to your patient)
Justice (doing right by society)
Principles of Giving Bad News
Things to avoid:
Breaking patient confidentiality
Collusion with relatives (the relatives know the diagnosis but the
patient doesn’t)
Assuming it is best for patients to not know the truth
Principles of Giving Bad News: SPIKES
Tool
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP (2000) SPIKES – A Six Step Protocol for Delivering Bad News: Application to the
Patient with Cancer. Oncologist 5:302-311
Consultation Skills for Giving Bad News
SETTING: Preparation – prepare yourself with the information,
patient (and if has relatives), found ideal location and no
interruptions
PERCEPTION: Assess base level of knowledge: What does the
patient know?
INVITATION: Assess amount of information to give: What does the
patient want to know? How much? Even if bad news?
Warning shot: ‘I’m sorry I have some bad news’
Consultation Skills (Continued)
KNOWLEDGE: Give information in chunks
Check understanding
Pause, allow time
EMPATHY: Allow denial, expression of feelings and listen to concerns
– listen, don’t interrupt
Use empathetic statements e.g. ‘I can see how upsetting this is
for you’, ‘I can understand how you felt that way’
SUMMARY / STRATEGY: Summary and plan
Offer availability
Stages of Grief
Denial – trying to avoid
Anger – frustrated outpouring of emotion
Bargaining – seeking for a way out
Depression – realization of the inevitable
Acceptance – finding a way forward
Kübler-Ross, E. (1969). On death and dying. New York, NY: Macmillan.
Jordanian Research
Identified learning needs for Jordanian doctors breaking bad news to
patients and relatives:
Consent, autonomy and confidentiality:
◦ Perceived occurrence that the doctor gained the patient’s consent before telling
others the diagnosis was 35.7%
First disclosure:
◦ 25.4% of patients received the diagnosis according to their preference
Withholding information:
◦ Greatest challenge for 62.1% of doctors was the relatives not wanting the patient to
know the diagnosis
◦ 93.2% of patients said they wanted the doctor to tell them the diagnosis even if
relatives had asked the doctor to withhold it
Jordanian Research (Continued)
Specific Communication Skills:
◦ Empathetic attitude
◦ Using a warning shot (considered to lessen the potential emotional reaction)
◦ Using physical touch appropriately (considered a learning need for doctors)
◦ Ascertaining the importance of faith for patients / relatives and using religious
phrases appropriately (this differs from the Western model of SPIKES)
◦ Managing moments of patient / relatives aggression
◦ Offering appropriate follow-up (this was perceived as a weakness in doctor’s
plan of action currently)
IGAD Framework (Salem & Salem 2013)
I – Interview: ask the patient if they would like relatives present and
facilitate this
G – Gather: gather information on the desired level of disclosure a patient
wants
A – Assess, Achieve: assess religious and family influences, achieve
rapport
D – Decide, Disclose, Discuss: decide on the appropriate level of
disclosure, disclose information slowly and simply, discuss and
summarise
What is Palliative Care?
Speciality that cares for the dying or with a terminal diagnosis that will not
get better e.g. cancer, end stage disease like heart failure. First hospice set
up in 1967 (a place where patients can die well in peace and are as
symptom free as possible)
Philosophy is that the focus is dying and we are not actively trying to `cure’
or `save’ the patient. May put them as `do not resuscitate’ or stop active
cancer treatments unless helps symptoms
Patient centred and holistic – look at physical, psychological and spiritual
elements of care for the patient
Manage symptoms e.g. pain, breathlessness, nausea and vomiting…
Phases and Layers of Care
Resources
Silverman J, Kurtz S, Draper J. - Skills for Communicating with
Patients
Douglas G, Nicol F, Robertson C. - Macleod's Clinical Examination
www.dummies.com/health/basic-principles-of-medical-ethics
www.oscestop.com/Breaking_bad_news.pdf
www.thepalliativecarehub.com/introduction-palliative-care
Acknowledgements
Special thanks to Dr David Harniess for his help in preparing this
lecture
