Palliative Care
The Center for
Education
Giving Bad News
Learning objectives
• List the 6 steps in giving bad news
• Adapt the bad news protocol to your work
setting
• Explain how the manner in which bad news
is given can impact patient outcome and
patient care
• Explain how culture impacts patient
information needs and decision-making
Consider a case
• 24-year-old F; HIV+ for 3 years; current IVDU
• Unstable living situation
• Estranged from family
• On HAART, but questionable adherence
• Recent abnormal LFTs
• You are meeting with her to give her a Hep C
diagnosis
Do physicians give bad news?
• 1961 Oken in JAMA • 1979 Novak in JAMA
• Survey of 219 • Survey of 264
physicians physicians
• 88% generally DID • 98% generally DID
NOT inform patients inform patients of a
of a cancer cancer diagnosis
diagnosis
Giving bad news
• Reviewing the evidence
• Recommendations for clinicians
• Cultural considerations
Reviewing the evidence
• What do patients want to know?
• How do patients experience bad news?
• How competent are physicians in giving bad
news?
• How should physicians give bad news?
• Does how bad news is given make a
difference?
• Do cultural differences matter?
What do patients want to know?
• 2,331 patients at UK cancer centers:
–98% wanted to know if the illness was cancer
–87% patients preferred “as much information
as possible”
• Need to individualize delivery to patient needs
Jenkins, Br J Cancer 2001;84:48-51
How do patients
experience bad news?
• Bad news results in a cognitive, behavioral, or
emotional deficit in the person receiving the
news that persists
• Clinicians can’t change the news
• Clinicians can make the news worse, or they
can help give realistic hopes
A variety of responses
to bad news
100 patients diagnosed with cancer:
– Shock 54%
– Fright 46%
– Accept 40%
– Sadness 24%
– Not worried 15%
Lobb, Med J Aust 1999: 290-4
Responses to bad news
4,527 patients tested for Huntington disease
• <1% experienced “catastrophic event”
–Including suicide, attempted suicide, psychiatric
hospitalization
• Increased risk associated with
–those with manifestations of Huntington’s
–those with previous psychiatric illness
–those who were unemployed
Almqvist, Am J Hum Genet 1999: 1293-1304
People receiving bad news may
not remember much
• Three months after parents received bad news
• 12 of 23 sets took in “little or none of the
information given”
• 4 of 23 sets denied that a separate information
session had occurred
• 10 of 19 sets remembered the information
session, but didn’t understand the content
Eden, Pall Med 1994: 105-114
Medical jargon can
make bad news worse
• Technical language frequently unclear
• 100 women with breast cancer:
–73% misunderstood “median survival”
–No agreement on what a “good” chance of
survival meant numerically
Ford, Soc Sci Med 1996: 1511-9
Physicians are inaccurate
in detecting distress
• 5 oncologists studied intensively
• None predicted patient distress better than
chance
• One had negative predictive behavior
• All very satisfied with their performance
• Little probing about patient emotional state
Ford, Br J Cancer 1994: 767-70
Patient and clinician stress
related to bad news
Clinician Patient
Stress
Encounter Time
Ptacek, JAMA 1996: 496-502
Gaps in what patients want
and what they receive
• Most patients are highly ‘satisfied’ yet:
–57% wanted to discuss life expectancy,
but only 27% actually did
–63% wanted to discuss the effects of
cancer on other aspects of life, but only
35% actually did
Lobb, Med J Aust 1999: 290-4
Pitfalls in giving bad news
• 79 patients, 68 family said bad news
encounter was suboptimal because:
–Physician was too blunt
–Place or time was inappropriate
–Patient got the sense that there was no
hope, they wanted physicians to balance
sensitivity and honesty
Curtis, J Gen Intern Med 2001: 41-9
How bad news is given
makes a difference
• 100 patients with breast cancer, adjustment to
illness correlated with:
–Physician behavior during cancer diagnostic
interview
–History of psychiatric issues
–Premorbid life stressors
• Patients dissatisfied with how physicians
provided information were 2x more likely to be
depressed or anxious
Roberts, Cancer 1994, 74 (1 supp): 336-41
A recommended protocol
for giving bad news
1. Prepare info, location, setting
2. Find out what they already know
3. Ask how much they want to know
4. Share the information
5. Respond to the patient’s emotion
6. Negotiate a concrete follow-up step
Buckman, How to Break Bad News, 1992
Bad news protocol
1. Prepare
• Know the facts
• Find time
• A quiet space
• The right people
Nonverbal cues: distance, posture, eye level
Bad news protocol
2. Find out what the patient already knows:
“I want to make sure we’re on the same page;
what have other doctors told you?”
“When you first had (symptom), what did you
think it might be?”
Bad news protocol
3. Ask how much the patient wants to know:
“Would you like me to tell you the full
details of your condition or is there
someone else you would like me to talk
to?”
Bad news protocol
4. Share the information:
Warning shot
“I have some bad news about the results of
your blood test.”
Bad news protocol
4. Share the information:
Use language at the same level as the
patient’s:
“Did you get that? Did that make sense to
you?”
Bad news protocol: Final steps
5. Respond to the patient’s emotions:
–Acknowledge, name, empathize
“I can see that this wasn’t something
you expected to hear.”
–You don’t have to agree with the emotion
or share it.
Bad news protocol: Final steps
6. Negotiate a concrete follow-up step:
“Let’s talk next week after you see the GI
specialist.”
Dealing with the fallout
• Walk through the bad news encounter
• Use case-specific knowledge
• Know usual clinician pitfalls:
–Failure to assess understanding
–Failure to acknowledge emotion
Survey of 800 patients in LA:
Assessing cultural differences
Should a patient:
Be told of a Decide
diagnosis about
of cancer life-
support
African-American 88% 60%
European-American 87% 65%
Mexican-American 43% 41%
Korean-American 35% 28%
Blackhall, JAMA, 1995; 274:820
Can discussing death cause harm?
• Studies have shown that people from many
different cultures are more likely to believe
discussing death can bring death closer:
–African-Americans
–Some Native-Americans
–Immigrants from China, Korea, Mexico
Curtis, Arch Intern Med, 2000; 60:1690
Caralis, J Clin Ethics, 1992; 4:155
Caresse, JAMA, 1995; 274:86
Exploring cultural beliefs
• What do you think might be going on?
• If we needed to discuss a serious medical
issue, how would you and your family want to
handle it?
• Would you want to handle the information and
decision-making, or should that be done by
someone else in the family?
Kagawa-Singer, JAMA 2001; 286:2993
Summary
• Giving bad news is a fundamental
communication skill
• How bad news is delivered can affect how
patients adjust to the illness
• Exploring cultural beliefs is important in
adapting the bad news communication to each
patient
Contributors
Anthony Back, MD Director
J. Randall Curtis, MD, MPH Co-Director
Frances Petracca, PhD Evaluator
Liz Stevens, MSW Project Manager
Thanks to Elizabeth Vig, MD, MPH, for her contributions to this
module.
Visit our Website at uwpallcare.org
Copyright 2003, Center for Palliative Care Education, University of Washington
This project is funded by the Health Resources and Services Administration (HRSA) and the Robert Wood Johnson Foundation (RWJF).
