FY2B14L4 DAGÍTAB 2026 WVSU – COLLEGE OF MEDICINE

Properly Breaking Bad News

Lecturer: Dr. Pasuelo l 05/16/ 2024 l 8:00 – 10:00 AM

OUTLINE It might simply be a diagnosis that comes at an

inopportune time (angioplasty during a holiday
I. Introduction
A. Definition season)
B. True or False A diagnosis that is incompatible with one’s
II. Barriers to Effective Communication of Bad News employment (tremors in a pianist)
A. Health Care Professional-Led Barriers • These will affect the patient’s perception and
B. Patient and Family Caregiver-Led Barriers experiences in the future negatively.
III. Patient’s Right to the Truth
A. Communication • Necessary Items to disclose:
B. Diagnostic Disclosure and Discussion about The patient’s current medical status, including the
Prognosis likely course if no treatment is provided
C. Transition to Palliation and End-of-Life Care The contemplated procedure or medication
IV. Strategies for Breaking Bad News Available alternative procedures or medications
A. ABCDE Mnemonic
Anticipated risks and benefits of procedures or
B. SPIKES Strategy
V. The Necessity of Fostering Faith and Hope in medications
Communicating with A Filipino Patient A statement offering opportunity to ask further
A. Faith and Hope questions
B. Takeaway Messages A professional opinion about the alternatives
SUMMARY • Don’t forget to ask open-ended questions (probing)
REVIEW QUESTIONS
TRANS COMM and your active listening skills (open-ended questions;
REFERENCES leading the patient to a certain topic; eliciting more
APPENDICES information from the patient; personal opinions)
Try to open the option for palliative chemotherapy
I. INTRODUCTION in order to lessen the symptoms.
• An elderly female, who have lived in a small farming To a palliative care specialist: there are many
barrio in a rural area all her life, became severely ill, options for the patient and it DOES NOT end with
and her daughter decided to bring her to Manila for “wala na ta may mahimo”.
o Support for the patient
consultation.
o Provide comfort to the dead and/or dying
• Patient was seen by a Family Physician and diagnostic
tests show that the patient has Advanced Stage 4 B. TRUE OR FALSE
cancer and no effective curative treatment is • Some physicians contend that breaking bad news is
available. an innate skill?
• The daughter asks the doctor not to tell her mother the FALSE
diagnosis because she fears that bad news would o Physicians who are good at discussing bad
sadden her parent. news with their patients usually report that
• As member of the health care team, how will you breaking bad news is a skill that they have
handle this situation? worked hard to learn.
o Studies of physician education demonstrate
A. DEFINITION that communication skills can be learned.
• Any information that seriously affect a person’s o All of us can communicate but we don’t know
if it’s bad or good sometimes.
perception and experience of the future in a negative
way.
• It is usually associated with a terminal illness, such as
II. BARRIERS TO EFFECTIVE
cancer (which is common nowadays). However, it can COMMUNICATION OF BAD NEWS
come in many forms (cancer, non-cancer diagnosis, A. HEALTH CARE PROFESSIONAL-LED BARRIERS
disability, loss of function): • Fear of their own emotions
Diagnosis of a chronic illness (COPD) Bracketing: a mental skill where you separate
Disability or loss of function (Glaucoma causing your own emotions so your judgment will not be
visual impairment) affected (or “blurred”).
Treatment plan that is burdensome, painful, or Not necessarily being non-chalant.
costly (dialysis) • Fear of patients and family caregiver’s emotions and
reactions
• Uncertainty in how to support these responses • May be embarrassed by own lack of knowledge
• Communicating information in technical language that You can assess this through observation: the way
is not easily understood they talk, dress up, their approach, how they
Medical terms or jargon respond to questions, etc.
Ilonggo terminology for pancreas, spleen, or any
body organs III. PATIENT’S RIGHT TO THE TRUTH
• Avoiding discussion of distressing information • Patients have the right to honest and full explanation
Doc uses individual and family counseling of their situation.
Talk to the the patient first before the family They should be told as much or as little as they
o The patient’s understanding about the want to know.
disease; what they think about the disease You will be causing a lot of distress to the patient
o Delve deeper on their beliefs if you fail to do this.
o Treatment options that they would want to Lead the patient to point out what their diagnosis
have is
o Then talk to the family o Presence of mass: might be malignant or
• Giving false hope – telling patients and benign tumor
family/caregivers what training doctors think they Advice the family how to approach the patient
want to hear • Patients have the right to decline information if they
It is important use terms that directly refer to what so wish.
you want the patient to understand • Without information about the disease and prognosis,
Avoid misconceptions patients cannot participate in their own treatment
o Crises may arise because of this planning, give informed consent to treatment, and
make suitable plans for themselves and their families.
B. PATIENT AND FAMILY CAREGIVER-LED BARRIERS
• Fear of what might be said
A. COMMUNICATION
• Not feeling prepared • Communication should be with the patient, unless the
• Feeling that people are not being truthful or honest patient is not competent, has delegated the
Bargaining responsibility to a family member, or subscribes to a
• Feeling that their decisions and hopes are not being religious or cultural custom that requires that the male
respected head of the family is told.
We fail to delve deeper into the patient’s wants Patient should be informed first before others.
and wishes. • Communication about sensitive matters should be
• May only be able to take in information a little bit at a carried out in an understanding, sensitive, and
time unhurried manner; be given in a way that can be
Sometimes, you were able to discuss the results understood; and be honest.
from the diagnostic exams. However, following
Counselling is a continuous session. You can’t
visit to the clinic, the patient may not remember
finish everything in one sitting.
everything you have told them because what will
• Telling patients nothing or lying to them is very likely to
now dominate will be their anxiety.
cause harm.
o This is why follow-up is very important in
counseling • Evidences from many countries and different cultures
• May have differences in what information they want that terminally ill patients fear the unknown more than
each other to know they fear the known and will suffer less, both physically
• May have a need to seek a second opinion and psychologically, when given the information they
Patients don’t trust your judgment want.
This is why it is important to communicate • Say nothing or telling lies will lead to a loss of trust
properly and effectively when the patient is informed of or deduces the true
• May have limited understanding of medical/ physical situation.
processes/ course of the disease • “There is nothing more that can be done”.
Very important FALSE!
Advanced directives
The family as well as the patient should
understand the disease process (mechanism;
pathology) behind the condition in order for them
to appreciate or realize the relevance of the
treatment

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 B. DIAGNOSTIC DISCLOSURE AND DISCUSSIONS Palliative care: manage the patient from the time
ABOUT PROGNOSIS of diagnosis until bereavement.
• There should be a truthful discussion of what therapy Hospice care: end-of-life
is or is not available and about the benefits and • Palliative Care should be discussed with the patient
burdens of any therapies. and their families in the context of how it can help
The patient should be informed (whether them achieve their goals of comfort and quality of life
applicable or not) all of the available medications. despite the life-limiting nature of their illness.
• Patients maybe told there is no further therapy for the • In situations where death is clearly imminent and
underlying disease, but more provision of continuing inevitable, end-of-life care discussions and advance
care and symptom control should be stressed (see care planning must be initiated.
Appendix A).
In any setting, palliative care should be given at IV. STRATEGIES FOR BREAKING BAD NEWS
the time of diagnosis (ideal). A. ABCDE MNEMONIC
The role of curative at the time of diagnosis is very • (Vandekieft, 2001)
extensive/big. However, as the illness trajectory of
the patient declines (worsening of the disease
ADVANCED PREPARATION
course), the role of the palliative team becomes
bigger – until death and bereavement care for the • Arrange adequate time and privacy, confirm medical
family. facts, review relevant clinical data, and emotionally
o Bereavement care should be 2 years prepare for the encounter.
o Part of the bereavement care: going to the • It is important for any healthcare provider to
burial, sometimes you would deliver the thoroughly review the case, not just the disease
eulogy. course, but also the laboratory results and
diagnostics. This is very important in dealing with
terminally-ill cases.
• Be prepared emotionally.
• Provide privacy.

BUILDING A THERAPEUTIC RELATIONSHIP

• Identify the patient’s preferences regarding the
disclosure of bad news.
Always ask the patient about their preferences
Diagram of the Extent of Palliative Care (see
and what they want to be discussed in the session
Appendix A)
(can be less or more).

• When discussing prognoses with the patient, the

COMMUNICATING WELL
uncertainty in estimating an individual prognosis,
• Determine the patient’s knowledge and
must be explained.
understanding of the situation, proceed at the
• Avoid precise prognostication, give a realistic time
patient’s pace, avoid medical jargon or euphemisms,
range and provide realistic hope.
allow for silence and tears, and answer questions.
Palliative Prognostic Index is an example
No sugarcoating of information!
Tools for the physician to assess what approach
There will be a good physician-patient relationship
to utilize for the patient.
if the physician is equipped with answering
Always go back to disease course and pathology!
whatever the patient asks: disease progression,
• Help patients to achieve what is important for them.
management, treatment options, and side
Recommend that family relationships and worldly
effects.
affairs be attended to, be prepared to answer
• Talk to the patient according to the level that they want
questions about the process of dying, provide
the conversation to go on.
ongoing support and counseling, and reassure
them about continuity of care. • Consider the educational background also.
DEALING WITH PATIENT AND FAMILY REACTIONS
C. TRANSITION TO PALLIATION AND END-OF-LIFE • Asses and respond to emotional reactions and
CARE empathize with the patient.
• Palliative care is an umbrella term, where the hospice Don’t be affected by hysterical patients.
care falls under.

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 o Acknowledge their reaction and ask why they • Give warning statements
reacted that way. “Unfortunately, I’ve got some bad news to tell you”
Also check for the reaction of the family. Stay o Go directly to what you want to tell the
vigilant and observant. patient.
“I’m so sorry to have to tell you…”
ENCOURAGING/VALIDATING EMOTIONS • Check Perception
• Offer realistic hope based on patient’s goals and deal “Do you see what I mean?”
with your own need. “Is this making sense so far?”
Check for the reaction!
B. SPIKES STRATEGY
• (Buckman, 2005) EMPATHY
• More commonly used • Addressing the patient’s emotions with empathic
responses (addressing emotions that might occur
SETTING UP during bad news disclosure and strategizing a
• How you start the interview or discussion. treatment plan)
• Setting up the interview (choosing the right location, • Ask probing questions
establishing rapport): “How does that make you feel?”
“What do you make of what I’ve just told you?
Privacy
Involve significant others • Respond to emotions, Identify the emotions and its
o The roles are very important: who will be the origin
decision-maker, financial provider, etc. “Hearing the result of the bone scan is clearly a
Look attentive and calm major shock to you”
Listening mode: silence and repetition “Obviously, this piece of news is very upsetting”
o Give time for silence. Give them time to “Clearly, this is very distressing”
process. • Validate and normalize feelings
Availability I can understand how you can feel that way
o Don’t just be there to deliver the news. • Remember: normalizing is part of counselling!

PERCEPTION STRATEGY AND SUMMARY

• Assessing the patient’s perception of the medical • Summarizing the information –the plan for the patient
situation – how much the patient knows and family.
“What did you think was going on with you when • Give the patient an opportunity to voice any major
you felt the lump?” concerns or questions.
“What have you been told about all this far?”
• Plan the next steps that need to be taken and the roles
“Are you worried that this might be something
the doctor and the patient will play in taking those
serious?”
steps.
• Doctor from California Syndrome: “Ngaa amo na
naubra mo, sa America amo ni.”
• Adjust to the level of the patient. V. THE NECESSITY OF FOSTERING FAITH
AND HOPE IN COMMUNICATING WITH A
INVITATION FILIPINO PATIENT
• Obtaining the patient’s invitation (asking the patient’s A. FAITH AND HOPE
permission to explain) – find out how much the patient • It is important to recall the socio-cultural and religious
wants to know. implications of the illness.
“Are you the kind of person who prefers to know • Many Filipino patients may accept this illness as God’s
all the details about what is going on?” plan for them and resort to prayer.
“How much information would you like me to give Prevalent in rural areas; very common.
about your diagnosis and treatment?” Reaction: ACCEPTANCE (FAITH determined
“Would you like me to give you details of what is destiny) – abstain from seeking medical
going on or would you prefer that I just tell about treatment and leave health issues in “the hands
treatments I am proposing?” of God”.
• Others may accept their planned destiny and strive to
KNOWLEDGE cope with this predetermined fate through medical
• Giving knowledge and information to the patient – treatment.
Share the information

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 Reaction: HOPE – despite poor prognosis and Distrust in truthfulness
severity of illness, one is optimistic for a cure. Limited understanding of medical conditions
• Ancient role of both PHYSICIAN and PRIEST is quite Need for a second opinion
appropriate in caring for many terminally-ill Filipino • Patient’s Right to the Truth:
patients. Patients have the right to know their condition and
• Filipinos’ philosophy concerning death is commonly can choose how much information they want.
connected to spiritual beliefs. Filipinos follow their Honest information is crucial for informed consent
and treatment planning.
religious traditions that the same Lord who has
• Communication Principles:
created them will reward them with eternal life in
Communication should be patient-centered
heaven.
unless the patient is incompetent or delegates the
• Rituals done in Filipino traditions emphasize the
responsibility.
significant role that both family and faith play in the Be honest, sensitive, and unhurried.
dying process of a terminally-ill Filipino patients. Avoid lies as they harm trust and increase fear of
the unknown.
B. TAKEAWAY MESSAGES • Diagnostic Disclosure and Prognosis Discussion:
• It is essential for the family physicians not only to know Truthful discussion about available therapies and
the strategies for breaking the bad news, but also to their burdens.
understand the cultural values that are pertinent to Avoid precise prognostication; provide a realistic
most Filipinos: extended family unit, faith-determined time range.
destiny and health, and patients emotional concerns Support patient’s goals and offer ongoing care
whether or not they are verbalized. and counseling.
• When caring for Filipino patients, health professionals • Transition to Palliative and End-of-Life Care:
specifically must become accustomed and sensitive to Discuss palliative care to focus on comfort and
quality of life.
their cultural background to holistically nurture the
Initiate end-of-life care discussions and advance
patients physically, emotionally, and spiritually.
care planning when death is imminent.
• ABCDE Mnemonic:
SUMMARY Advanced Preparation: Arrange time, privacy, and
• Definition of Bad News: review clinical data.
Bad news is any information that negatively Building a Therapeutic Relationship: Understand
impacts a person’s perception of their future, patient’s preferences.
often associated with terminal illnesses like Communicating Well: Use clear, simple language
cancer but can include chronic illnesses, and proceed at patient’s pace.
disabilities, or burdensome treatments. Dealing with Reactions: Empathize and respond
• Necessary Disclosures: to emotional reactions.
Current medical status and prognosis without Encouraging/Validating Emotions: Offer realistic
treatment hope based on patient’s goals.
Details of contemplated procedures or • SPIKES Strategy:
medications Setting Up: Choose the right location, involve
Available alternatives significant others, and be attentive.
Anticipated risks and benefits Perception: Assess the patient’s understanding
Opportunity to ask further questions and knowledge.
Professional opinion on alternatives Invitation: Ask the patient how much they want to
• Physician Skills: know.
Breaking bad news is not innate but a skill that Knowledge: Share information with warning
can be learned and developed through training. statements and check understanding.
Empathy: Address emotions with empathy and
• Health Care Professional-Led Barriers: validate feelings.
Fear of emotions (their own and the patient's) Strategy and Summary: Summarize information,
Uncertainty in supporting emotional responses plan next steps, and ensure the patient
Use of technical language understands.
Avoidance of distressing information • Fostering Faith and Hope with Filipino Patients:
Giving false hope Recognize the importance of socio-cultural and
• Patient and Family Caregiver-Led Barriers: religious implications.
Fear of the information Faith and hope play a crucial role in Filipino
Unpreparedness patients' coping mechanisms.

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 Acknowledge the dual role of physician and priest 7. In the SPIKES strategy, what does the 'P' stand for?
in caring for terminally-ill Filipino patients. A. Preparation
Understand the spiritual beliefs and family B. Perception
involvement in the dying process. C. Patience
D. Permission
REVIEW QUESTIONS
1. Which of the following is NOT typically considered bad 8. Which cultural consideration is important when
news in a medical context? communicating with Filipino patients?
A. Diagnosis of a chronic illness A. Emphasizing independence from family during
B. Winning a lottery decision-making
C. Disability or loss of function B. Recognizing the role of faith and religious beliefs
D. A burdensome treatment plan C. Ensuring all communication is done in English
D. Avoiding any discussion of prognosis
2. Which of the following is true about breaking bad news
according to studies of physician education? 9. Which of the following strategies is NOT part of the
A. It is an innate skill. SPIKES framework?
B. It cannot be learned. A. Setting up the interview
C. It is a skill that can be developed through hard B. Assessing the patient’s knowledge
work. C. Inviting the patient to hear the news
D. It should be avoided whenever possible. D. Providing false hope to comfort the patient

3. Which of the following is NOT a healthcare professional- 10. What should be avoided when discussing a patient’s
led barrier to effective communication of bad news? prognosis to ensure realistic hope is maintained?
A. Fear of their own emotions A. Providing a realistic time range
B. Use of technical language B. Discussing the uncertainty in estimating an
C. Limited understanding of medical processes by individual prognosis
the patient C. Giving precise and exact prognostication
D. Avoidance of distressing information D. Recommending that family relationships and
worldly affairs be attended to
4. What right do patients have regarding information about
their disease and prognosis? Answer: 1B, 2C, 3C, 4B, 5B, 6B, 7B, 8B, 9D, 10C
A. The right to be told everything, regardless of their
wishes. TRANS COMM
B. The right to honest and full explanation of their Prepared by: Corpuz, Distajo, Openiano
situation. Editor: Corpuz
C. The right to receive false hope to maintain Checker: Bernas
optimism.
D. The right to only hear positive aspects of their
condition.

5. In which scenario should communication about a

patient’s condition be primarily directed towards a family
member instead of the patient?
A. When the patient is competent and wants to know
everything.
B. When the patient has delegated the responsibility
to a family member.
C. When the healthcare provider feels the patient will
react badly.
D. When the diagnosis is not yet confirmed.

6. Which mnemonic is used to describe the strategy for

breaking bad news, including steps like Advanced
Preparation and Building a Therapeutic Relationship?
A. SPIKES
B. ABCDE
C. CARE
D. HOPE

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REFERENCES
1. Pasuelo, A.R. (2024). Properly Breaking Bad News
(Breaking Bad News and Communication Along the
Disease Trajectory). Powerpoint Presentation.

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APPENDICES
APPENDIX A

Diagram of the Extent of Palliative Care

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