Breaking Bad News

Dr Evaristo Kunka
 Introduction
• Breaking bad news to patients is one of the most difficult responsibilities in the practice of
medicine.

• Although virtually all physicians in clinical practice encounter situations entailing bad news,
medical school offers little formal training in how to discuss bad news with patients and their
families.

• This article presents an overview of issues pertaining to breaking bad news and practical
recommendations for clinicians wishing to improve their clinical skills in this area

• The biomedical model in medical training places more value on technical proficiency than on
communication skills.
 Defi nition

• B a d n e w s i s “a ny n e w s t h a t d r a sti ca l l y a n d n e g a ti v e l y
a l te r s t h e p a ti e nt ’s v i ew o f h e r o r h i s f u t u r e .”

• P r o fe s s i o n a l b i c y c l i st L a n ce A r m st r o n g ’s r e co l l e c ti o n o f
b e i n g d i a g n o s e d w i t h m e ta sta ti c te sti c u l a r ca n ce r :
• “ I l e ft m y h o u s e o n O c t o b e r 2 , 1 9 9 6 , a s o n e p e r s o n a n d
c a m e h o m e a n o t h e r.”
 Characteristics of bad news

• Bad news is stereotypically associated with a terminal

diagnosis, but p hy s i c i a n s e n c o u n t e r m a ny s i t u a ti o n s t h a t
i nv o l v e i m p a r ti n g b a d n e w s ;
• A p r e g n a n t w o m a n ’s u l t r a s o u n d v e r i fi e s a f e t a l d e m i s e ,
• A middle-aged w o m a n ’s m a g n e ti c resonance imaging scan
c o n fi r m s t h e c l i n i c a l s u s p i c i o n o f m u l ti p l e s c l e r o s i s ,
• A n a d o l e s c e n t ’s p o l y d i p s i a a n d w e i g h t l o s s p r o v e t o b e t h e o n s e t
of diabetes.
Patient response to Bad news
• How a patient responds to bad news can be influenced by the patient’s psychosocial context.
• A diagnosis that comes at an inopportune time, such as unstable angina requiring angioplasty during the
week of a daughter’s wedding.
• A diagnosis that is incompatible with one’s employment, such as a coarse tremor developing in a
cardiovascular surgeon.

• Physicians have faced a conference room full of family members awaiting news about the patient,

• Physicians are sometimes pulled aside for a hallway discussion with the request to withhold the

conversation from the patient or other family members

 Why Breaking Bad News is
Diffi cult

T h e l i fe o f a s i c k p e r s o n ca n b e s h o r te n e d n o t o n l y b y t h e
a c t s , b u t a l s o b y t h e w o r d s o r t h e m a n n e r o f a p hy s i c i a n
Patient related factors
• Traditional paternalistic models of patient care have given way to an emphasis on patient
autonomy and empowerment.

• Studies on patient preferences regarding disclosure of a terminal diagnosis found that 50 to

90 percent of patients desired full disclosure.

• Because a sizable minority of patients still may not want full disclosure.

• The physician needs to ascertain how the patient would like to have bad news addressed.

• The physician faces the challenge of individualizing the manner of breaking bad news and the
content delivered, according to the patient’s desires or needs
 Physician Related factors
 Physicians also have their own issues about breaking bad news.

 It is an unpleasant task.
 P h y s i c i a n s d o n o t w i s h t o t a k e h o p e a w a y f r o m t h e p a ti e n t .

 T h e y m a y b e f e a r f u l o f t h e p a ti e n t ’s o r f a m i l y ’s r e a c ti o n t o t h e
n e w s , o r u n c e r t a i n h o w t o d e a l w i t h a n i n t e n s e e m o ti o n a l
response.
 B a d n e w s o ft e n m u s t b e d e l i v e r e d i n s e tti n g s t h a t a r e n o t
conducive
t o s u c h i n ti m a t e c o n v e r s a ti o n s .
Physician Related factors

• Physicians may feel unprepared for the intensity of breaking bad news, or
they may unjustifiably feel that they have failed the patient.

• Effect of these factors is physician uncertainty and discomfort, and a

resultant tendency to disengage from situations in which they are called on
to break bad news.

• Clinicians focus often on relieving patients’ bodily pain, less often on their
emotional distress, and seldom on their suffering
Approach to delivering Bad News

• A number of strategies have been developed for the delivery of bad news

• Rabow and McPhee developed a practical and comprehensive model,

synthesized from multiple sources, that uses the simple mnemonic ABCDE

• These recommendations are intended to serve as a general guide and

should not be viewed as overly prescriptive
The ABCDE approach

• A–advance preparation

• B–build a therapeutic environment/relationship

• C–communicate well

• D–deal with patient and family reactions

• E–encourage and validate emotions

Advance preparation

• Arrange for adequate time, privacy and no interruptions (turn pager

off or to silent mode).

• Review relevant clinical information.

• Mentally rehearse, identify words or phrases to use and avoid.

• Prepare yourself emotionally

Build a therapeutic environment /
relationship

• D e t e r m i n e w h a t a n d h o w m u c h t h e p a ti e n t w a n t s t o k n o w.

• H a v e fa m i l y o r s u p p o r t p e r s o n s p r e s e n t .

• Introduce yourself to everyone.

• Wa r n t h e p a ti e n t t h a t b a d n e w s i s c o m i n g .

• U s e to u c h w h e n a p p r o p r i a t e .

• S c h e d u l e fo l l o w - u p a p p o i n t m e n t s
Communicate well
• A s k w h a t t h e p a ti e n t o r f a m i l y a l r e a d y k n o w s .

• Be frank but compassionate; avoid medical jargon.

• A l l o w f o r s i l e n c e a n d t e a r s ; p r o c e e d a t t h e p a ti e n t ’s p a c e .

• H a v e t h e p a ti e n t d e s c r i b e h i s o r h e r u n d e r s t a n d i n g o f t h e n e w s ;
r e p e a t t h i s i n f o r m a ti o n a t s u b s e q u e n t v i s i t s .

• A l l o w ti m e t o a n s w e r q u e s ti o n s ; w r i t e t h i n g s d o w n a n d p r o v i d e
w r i tt e n i n f o r m a ti o n .

• Conclude each visit with a summary and follow-up plan

Deal with patient and family
reactions
• A s s e s s a n d r e s p o n d to t h e p a ti e nt a n d t h e fa m i l y ’s
e m o ti o n a l r e a c ti o n ; r e p e a t a t e a c h v i s i t .

• B e e m p a t h e ti c .

• D o n o t a r g u e w i t h o r c r i ti c i ze co l l e a g u e s
Encourage and validate
emotions
• E x p l o r e w h a t t h e n e w s m e a n s to t h e p a ti e nt .

• O ff e r r e a l i sti c h o p e a cco r d i n g to t h e p a ti e nt ’s g o a l s .

• U s e i nte r d i s c i p l i n a r y r e s o u r ce s .

• Ta ke ca r e o f y o u r ow n n e e d s ; b e a tt u n e d to t h e n e e d s
o f i nv o l v e d h o u s e sta ff a n d o ffi ce o r h o s p i ta l p e r s o n n e l
 Conclusion

• Despite the challenges involved in delivering bad news, physicians can find
tremendous gratification in providing a therapeutic presence during a patient’s
time of greatest need.

• A growing body of evidence demonstrates that physicians’ attitude and

communication skills play a crucial role in how well patients cope with bad news

• Both patients and physicians will benefit if physicians are better trained for this
difficult task.
Case studies