Very Good Guidelines on Breaking Bad News by Pallium India Trust as per this Lecture in Course

1. Communicating Bad News
or
Breaking Bad News

2. A close friend of your family,
Mrs. S., aged 38 years
was investigated recently.
Report confirms diagnosis of breast cancer.
How will you convey this diagnosis?

3. “I have seen the reports.
You seem to have cancer”

4. • A situation where there is no feeling of hope
• Threat to a person’s mental or physical
well-being
• A risk of upsetting an established life style
• A message which conveys to a person that
choices in his/her life may be reduced
What is bad news?
?

5. To tell
or
Not to tell ?

6. • Cannot cope with life!
• “She will never be able to bear it”
• “He will commit suicide”
Shows ‘Protective’ nature of family
Why does the family ask us not to tell
their loved one?

7. Importance of Telling the truth
 People have the Right to know
 Permits patients, families to plan, cope
 Reduces uncertainty. Avoids false hope
 Builds physician-patient trust
 Co-operate with treatment
But how do we know who can take it and who cannot?!

8. To tell or not to tell
is not the question
How to tell is important
(If the patient wants to know)

9. “I don’t know what to say” Dr. Robert Buckman
Learning Communication skills
bridges the communication gap,
makes the ‘pain’ easy to bear.

10. 1. Setting the scene - Getting started
2. Patient’s Perception - What does the patient know?
3. Inviting patient - How much does he want to know?
4. Knowledge of his disease - Sharing the information.
5. Emotions - Responding to patient‘s / family’s feelings
6. Summarising - Planning and follow-up
Adapted from Robert Buckman
S P I K E S 6 – Step Protocol

11. The Technique of Breaking Bad News
Communication techniques are like basic manners!
Use the skills in all your interviews!
1. Seating and Greeting – Introduction, addressing by
name, basic courtesies and politeness
2. Eyes Same level – sitting down, No barrier
3. Relaxed posture
4. Lean forward , show that you are LISTENING

12. Step 1: Setting the scene – Getting started
• Plan what you will say
- Confirm medical facts, Confirmed diagnosis
- Anticipate questions. Be prepared to respond.
- Knowledge of prognosis
• Maintain a Private environment

13. Step 2: Patient’s Perception –
What does the patient know?
Find out what the patient knows:
With Open Questions:
“What do you know about your illness?”
“What did your doctor tell you ?”
Listen…….

14. Step 3: Inviting patient –
How much does the patient want to know?
Appropriate questions:
“Do you want to know more about your disease?”
Patient may say: “Its enough if you can relieve my pain,
I do not wish to know”
Do not thrust information!
Finish the interview with appropriate hope

15. Step 3: How much does the patient
want to know?
Doctor: “Would you like me to tell you more
about your disease ?”
Patient : “Yes, I want to know, please tell me”

16. Step 4: Knowledge of his disease
Sharing the Information (bad news)
 A. Give a ‘warning shot’ Pause..
 B. Say the news (diagnosis) Pause..
A. Warning shot – examples :
“It looks like what you have is not the usual (or ‘ordinary’)
kind of ‘swelling’ (or ‘wound’)”
“What you have is something that may be difficult to cure”
or, “not possible to operate on”

17. Step 4: Sharing the information - two stages
Having given the Warning Shot,
B. Say the diagnosis, then stop, Pause..
• avoid medical terms, pause frequently
• check for understanding
• use silence, body language
• avoid monologue, promote dialogue

18. Step 5: Emotions - Responding to feelings
Give time to react
•Listen quietly, attentively, allow ventilation of feelings
•Use nonverbal communication
•Encourage descriptions of feelings – Example:
“What are your feelings after what I’ve just told you?”
Listen, Acknowledge feelings – “I see you are very upset”
Or, “I can quite understand your anger..”

19. Step 6: Summarising - Planning, follow-up
• Explain Plan for the next steps, as needed:
- Any additional information, tests needed
- Treat symptoms, referrals as needed
• Discuss potential sources of support
• Reassure availability and Continuity of Care
• Always give Realistic hope

20. Communication is like a Prescription!
 The Right drug (information)
 For the Right reason - (according to patient’s emotions)
 At the Right time (when patient is ready for it)
 Given in the Right Dose (in bits - on a need to know basis)

21. Communicating Bad News –
How can we reduce the unpleasant experience?
• Preparation and gentle honesty
• Use clear language, pause now and then
• Do not thrust unasked information !
• Give time to ‘sink in’ the information
• Give appropriate hope, availability of treatment
• Offer continuity of care

22. – To Patient or Care giver
• Progress of disease / Cancer metastasis
• When patient is in advanced stage
• In a terminal condition or at end-of-life
Other Clinical Situations where
‘Bad news’ may have to be conveyed:

23. Communicate Effectively by…..
• Asking before telling
• Pausing
• Taking the cue from the patient
• Acknowledging after their Emotion
• Responding: Open question / Empathic response

24. Breaking the Bad News - Summary

25. Importance of attempting to break the Bad News -
 Patient has a right to know
 Not telling may do more harm than good
 Do not tell if he does not want to know
 To tell or not to tell is not the issue
HOW to tell is important !