Breaking bad news to a patient may be viewed as one of the most difficult areas within the job of a doctor. However, it's an essential skill that all doctors have to do throughout their entire careers. Bad news may be defined in a variety of ways, including 'any information which adversely and seriously affects a patient's view of his or her future'.
In the context of medicine, some examples of bad news situations include disease diagnoses, disease recurrence, failure of treatment, prognostication of outcomes, presence of side effects, results of genetic tests, or raising the issue of palliative care and resuscitation.
The result of any bad news is that the patient's perspective on their future will alter irrevocably, potentially resulting in a very different future and lifestyle.
It's acknowledged within many studies that the way in which the news is given by the doctor has a major impact on the patient. The results of the studies suggest that accepting the physician's behavior by the patients is associated with the way of breaking the bad news to patients, that in 95% of cases, those physicians were accepted by patients who showed emotional and sympathetic behavior with the patients in breaking the bad news. So it is important that the information is conveyed in the most appropriate manner.
Delivering bad news is as dependent on verbal skills as non-verbal ones, it's crucial for the deliverer of the news to be aware of their own verbal and non-verbal cues as well as those of the patient. If the delivery of the bad news is done well, patients are able to continue with the consultation and maybe even help contribute to the decision-making process.
Based on the studies conducted, the effective and timely use of communication skills in breaking bad news by physicians will also improve the quality of treatment. From this perspective, effective communication between the doctor and patient forms an essential crux of breaking bad news. Since it allows for adequate exploration of the patient's expectations of the treatment and encourages their involvement in the development of the plan of care.
Why is breaking bad news so difficult?
Simply being present when the son is in great another person is in great distress can make breaking bad news difficult. There are other reasons, a recent study in Canada explored resident's perceptions about delivering bad news. It showed that the lack of emotional support from other health professionals, their own personal fears about the process, and the amount of time they had available to deliver bad news kept them from being effective in their roles.
Some of the weakest areas in the process of delivering bad news are exploring patient's reactions, imparting the information at the patient's pace, and providing written materials.
Physicians bearing bad news can feel helpless especially there are no active treatment options available to the patient. In certain circumstances, you may even feel guilty (usually inappropriate). Sometimes your own sense of morals looms. So it's not surprising may find themselves camouflaging the whole truth from the patient in an effort to avoid either the patient's or their own emotional reactions to the bad news.
Truth-telling, now and then
The debate about the amount and levels of truth given to patients about their diagnosis has developed significantly over the last few years. While some healthcare professionals may now increasingly share information with patients, it had once been the rule rather than the exception to withhold information because it was believed to be in the best interests of the patient.
The debate in the past was whether to tell patients bad news. Because it now is generally held that all mentally component patients have absolute tights to any medical information that they require or request, the debate has moved from 'whether to tell' to 'how to tell' or more importantly, 'how to share the information'.
As has been said many times, the manner in which you tell the truth may be even more important than the fine details of the information. Insensitive truth-telling can be just as harmful as insensitive concealment. This is where having a strategy for breaking bad news can help you.
Strategy for breaking bad news
There should be a good plan for determining the patient's values and wishes for participation in decision-making, and a strategy for addressing their distress when the bad news is disclosed can increase the physician's confidence in the task of disclosing unfavorable medical information. It may also encourage patients to participate in difficult treatment decisions. Finally, physicians who are comfortable with breaking bad news may be subject to less stress and burnout.
There are multiple models of breaking bad news that have been proposed and utilized effectively over the years. These models help guide and improve breaking bad news among doctors. Probably the most utilized models are the SPIKES and ABCDE models, However, there are several others that have been described and used including the BREAKS protocol and the Kaye 10-step approach.
The common themes across all these models and guides are described below:
Preparing for breaking bad news session
It's advised that prior to the session, the doctor who will take the role of delivering bad news fully reviews the case and familiarizes themselves with the patient's records including previous treatments and results. It's also useful to note any previous discussion with other healthcare staff to gain an idea of how much the patient already knows and their expectations.
Mental preparation, scripts, rehearsing, and anticipation of difficult questions about prognosis and treatment failure are also suggested steps to prepare for the session.
Preparing the setting/environment
Privacy, where the bad news is delivered can have a significant effect on the outcome of the session. Ideally, the session should be conducted face-to-face in a private consultation room, away from the rest of the patients. Doctors should ask patients whether they would like someone to be present during the patient since some patients like to have family members or friends with them when they receive the news. The presence of someone who has been involved with the patient may offer emotional support to the patient.
Before your important discussion, an environment free from interruptions should be achieved by setting out time constraints on the session, and also by handing over mobile phones or bleeps to colleagues during the duration, this way you can ensure your patient knows you are available.
Exploring the patient's knowledge, perception & expectations
The doctor should be able to probe the patient regarding what they understand about the condition, their perception, and expectations by using open-ended questions. By doing this, the doctor is able to identify the deficiencies of information and any misconceptions and address them in the discussion.
Perception, this step is the center of the 'before you tell, ask' principle. Before you break bad news to your patients, you should glean a fairly accurate picture of their perception of the medical situation. It's important to note any unrealistic expectations with treatment and diagnosis.
Exploring how much information the patient wants to know is also essential, because although must patients are receptive and want to know all the details, you cannot always assume that this is the case.
It has been shown that avoidance of bad news is a valid psychological coping mechanism in patients with cancer and other health threats.
Clear and direct communication with the patient
All models emphasize the importance of clear communication, the usage of medical jargon should be avoided, with layman terms used as much as possible. 'Use the same language your patient uses', this technique of aligning or matching terminology is important because even the most well-informed patients find technical terms hard to comprehend and remember during enormous emotional turmoil.
Information should be delivered in the amount expected by the patient in a clear, truthful, and direct manner, avoiding vague terms and sentences that may be misunderstood by the patient later. You may also need to repeat some points several times, particularly when the patient looks nonplussed even if they say they understand.
Any concern about information being misunderstood by language barriers should be addressed by the use of professional translators who could be brought in for the session, or fellow health-care professionals who speak the language. The doctor may invite the patient to ask questions for clarity and allow time for important points to be absorbed by allowing pauses and silence.
The emotional aspect of the discussion
For most physicians, responding to a patient's emotions is one of the most difficult parts of breaking bad news. Patients receiving bad news are likely to experience a multitude of emotions such as denial, anger, and sadness. By recognizing these emotions via verbal and non-verbal cues, the doctor can acknowledge and address these emotions.
Simple gestures like handing over a tissue or saying 'I can see that you are very upset with the news' are very effective. These empathetic responses show your patient that you understand the human side of the medical issue and that you recognize these feelings are normal.
By showing empathy towards the patient, the patient is more likely to trust the doctor and become more receptive during the discussion. It also facilitates the progress of the discussion, as a highly anxious and upset patient is less likely to want to absorb information compared to a calm one.
Summarising the session
One of the best ways to prepare a patient for participation in planning ahead and sharing decision-making about treatment options and future care is to ensure that they understand the information you have provided. It's helpful to regularly ask your patients whether they have understood the information discussed so far and to invite them to ask questions.
As a closure to the session, summarize the information and give your patient an opportunity to voice any of their major concerns that have arisen.
In some instances, the sessions may end with unanswered questions and concerns, and in these situations, further sessions with the patient or arranging family conferences might be useful.
Significance of cultural issues in breaking bad news
Interacting with patients facing life-limiting illness can be a rewarding experience. Yet, for many clinicians, it also remains one of the most challenging aspects of their work. Cultural and ethnic differences further complicate matters.
Patients present with varied desires, beliefs, and cultural practices, and navigating these issues presents clinicians with unique challenges. Astute clinicians recognize that communication with each patient and family is a unique experience.
Each patient should be seen as an individual with their own unique needs rather than just another 'number' in a busy clinic. This individualization can only be achieved if the patient is made the center of attention. Some essential elements of such a patient-centered approach would include the demonstration of compassion, and respect, allowance made for the expression of their feelings and emotions, listening patiently to their concerns, and making an effort to build an early relationship with the patient.
As professionals, we are expected to acquire and use good communication skills. Respect for patient's views, ideas, and beliefs, is especially important in minority groups, where diversity of attitudes exists.
Although the global trend toward disclosing the truth to patients is increasing, and disclosure may be considered an important practice today in Western countries, this is not the same for many non-Western countries. These practices vary among countries, cultures, religions, and social backgrounds. In some cultures, patients do not want to know their diagnosis and their families do not want them to know their diagnosis.
In some countries, such as China, direct disclosure is now required by law. Developed countries such as the United States had a similar practice of nondisclosure five decades ago. However, this practice has changed rapidly during the last quarter of the century, and breaking bad news to the patient has become an important aspect of patient care.
Cultural diversity is complex. There is a great variety within ethnic minorities. It is impossible to meet every culture's needs. A practical approach should aim to identify differences, be aware of them, and set up basic standards.
Western culture stresses individuality and personal independence. The patient is regarded as the focal point throughout the discussions and decision-making. They may ask for a family member to become involved in the process but remain in overall control. This view may not be welcomed by cultures, such as Asians, Arabs, and Eastern Europeans. In this group, there is more emphasis on the decision-making by the whole family together.
Awareness of ethnicity is crucial to providing on individualized and truly holistic care in a multicultural society. Health professionals must display an understanding of cultural and religious diversity, respect for an individual's faith, beliefs, and values, and recognize this need.
To ensure an improved understanding of this issue, hospitals should organize workshops and events to educate medical health professionals about traditions, culture, and beliefs. Volunteers from ethnic minorities should be invited to speak about their ways of life. This way not only the patient's experience will be improved, but the medical staff would also feel professionally satisfied.
Breaking bad news is a part of the art of medicine. A bad news is always a bad news, however well it is said. But the manner in which it is conveyed can have a profound effect on both the recipient (the patient) and the giver (the physician).
Breaking bad news is a complex yet important communication skill that all doctors must be able to execute well. There are many benefits of breaking bad news, not only for the patient but also for the medical team managing the patient. It empowers and informs the patient and allows them to plan ahead.
There are multiple models and guides that help doctors break bad news, all commonly promoting the importance of preparation prior to the session, gaining an understanding of what the patient knows, how much they want to know, clear communication, and addressing their concerns and emotions.
The task of breaking bad news will never be easy, but having a plan of action and knowing that you can support your patient through this difficult time should help considerably.