BREAKING
Prof.Dr. Utham Murali.
Dept.Of Surgery
D Y Patil Medical College
Mauritius.

QUOTE -

Contents of Discussion
 Definition / Examples
 Facts of Bad News
 Methods / Protocols
 Description of 1 method
 Key Points

What is Bad News?
 ‘Situations where there is either a feeling of no hope, a
threat to person’s mental or physical wellbeing, risk of
upsetting an established lifestyle, or where a message is
given which conveys to an individual fewer choices in his
or her life.’ Bor et al., 1993
 ‘...any information which adversely and seriously affects an
individual’s view of his or her future’. Buckman, 1992
 ‘...any information that is not welcome’. Arber and
Gallagher, 2003
 ‘...[an] uncomfortable experience for both the giver and the
receiver’. Aitini and Aleotti, 2006.

Examples
 Life threatening illness. eg: Cancer, HIV
 Degenerative conditions. eg: Alzheimer /
dementia
 Chronic illness. eg: Rheumatoid arthritis /
Systemic lupus erythematosus
 Mental retardation in children. eg: Downs
syndrome / Cerebral palsy

Other Situations
 Disease recurrence / spread of disease,
or
 Failure of treatment to affect disease
progression,
 Irreversible side effects, results of genetic
tests, or
 Issue of palliative care and resuscitation.

Why should it be done?
 Forms part of clinical practice.
 A skill that can be taught and improved.
 Patients and relatives appreciate it.
 The degree to which news is bad depends
on the gap between reality and patient’s
perception.
 Non disclosure is no longer considered
ethical.

Why should it be done?
 Better psychological adjustment by
patient.
 Reduces stress in doctors.
 Facilitates open discussion among
patients, relatives and doctors.
 Empowers patients by allowing them a
greater say in treatment.

So,
 Bad news is, therefore, a relative
concept and should depend on the
 patient’s interpretation of information
and reaction to it.

Why is it difficult ?
The Patient’s Perspective
 Patients often have vivid memories of
receiving bad news.
 Negative experiences can have lasting
effects on anxiety and depression
 Can facilitate adaptation to illness and
deepen the patient-doctor relationship

Why is it difficult ?
The Physician’s Perspective
 Fear of causing pain / being blamed / fear of
therapeutic failure / emotional reaction
 Lack of training in breaking bad news
 Lack of time / health system constraints / lack of
support from colleagues
 Cultural constraints / language barriers
 Fear of upsetting the patient’s existing family
roles or structure.

To Whom the BBN to be Given ?
 Certain legal and ethical guidelines in clinical
practice make it difficult to withhold important and
personal information.
 It is good practice first to discuss these situations
with a colleague or within a multidisciplinary health
care team.
 There are some specific situations in which you may
need to consider whether to give bad news.

Example -
 If a patient is deemed to be psychotic, and
presumably may not understand what has
happened, there may be reason to
withhold bad news.
 When treating a child, one usually confers
with the parent or guardian before
breaking bad news.

Who should give the Bad news ?
 For several reasons, it may be more
appropriate for another doctor to break
bad news.
 For example, a patient sent to a hospital
for special tests may still expect his or her
GP to reveal the results, rather than the
hospital consultant.

Contd -
 The GP usually has an established relationship
with the pt and presumably could anticipate
some of the problems that might arise.
 Giving bad news usually requires time, so it may
be inappropriate for someone to do so at the
end of a shift.
 It may be preferable to hand over the task to
other colleagues, provided they are fully briefed
and acquainted with the case.

When should bad news be given ?
 You can try gradually to break the news; this in
turn gives the patient and relatives time to
adjust.
 On the other hand, withholding the news may
deny them the opportunity to face up to it and
begin to make the necessary adjustments in
their personal lives.
 In some situations, it can actually be hazardous
to withhold bad news until a later stage.

Example -
 If the patient has an infectious disease or
condition (e.g. hepatitis C or HIV
infection), he or she can inadvertently
infect someone else, or be denied the
benefits of early medical information if not
fully informed of this condition.

What do patients want?
For themselves…
 more time to talk
 and show feelings
From the doctor…
 more information, caring,
hopefulness, confidence
 a familiar face

Methods to Deliver -
 Rabow and Mc Phee’s - ABCDE approach.
 Baile & Buckman - SPIKES approach.
 SAAIQ emergency approach - Pakistan
 BREAKS approach by IJPC
 SAD NEWS approach – Q.U / Canada

ABCDE Approach -
 A dvance preparation .
 B uild therapeutic environment .
 C ommunicate well.
 D eal with patient and family
reactions
 E ncourage and validate emotions

SPIKES Approach -
 S etting up in privacy.
 P erceptions of the patient.
 I nvitation to break news.
 K nowledge.
 E motions.
 S trategy.

SAAIQ Approach -
 SET the scene as soon as possible.
 ASSESS the understanding of the
attendant.
 ALERT them that I have bad news .
 INFORM in clear, understandable words.
 QUICKLY repeat summary of the situation.

BREAKS Approach -
 B ackground
 R apport
 E xplore
 A nnounce
 K indling
 S ummarise

SAD NEWS Approach -
 S et up & Sit down
 A sk , don’t tell
 D eliver the news
 N o fancy lingo
 E xpect, permit & respond to emotion
 W ait
 S upport & Summarise

 SPIKES APPROACH

S etting the Environment -
 Provide privacy
 Introduce self
 Determine who else should be present
 Ensure no interruptions
 Provide comfortable space
 Create welcoming environment

Perception
 Ask what he already
knows about the
medical condition or
what he suspects.
 Listen to level of
comprehensions.
 Accept denial but do
not confront at this
stage.

Invitation - Information
 Ask patient if s/he
wishes to know the
details of the medical
condition and/or
treatment.
 Accept patient’s right
not to know.
 Offer to answer
questions later if s/he
wishes.

Knowledge
 Deliver the message
 Use plain language
 Be mindful of body language
 Get to the point
 Give information in small chunks
 Pause
 Wait for reaction
 Use “teach back” to verify that message was
received

Emotions and Empathy
 Be prepared for patient’s and family’s emotional
response
 Anticipate fear, anger, sadness, denial, guilt
 Be mindful of your own response
 Comfort the patient

Strategy and Summary
 Assess patient’s readiness for planning
 Negotiate next steps
 Verify support structure
 Acknowledge & answer questions
 Summarize plan
 Use “teach back” technique
 Follow-up

Response to Reaction -

If pt Cries -
 Allow sometime to cry.
 Could say, “I can see you are very upset”
 Could touch the patient appropriately.
 After a few moments you should continue
talking even if patient continue to cry.

If pt – Angry
 Defensive or irritation with patient are
unhelpful.
 Acknowledge patient’s position and avoid
talking about it.

If pt refuses – Accept Diagnosis
 Explore reasons for patient’s denial.
 Do not be combative.
 Appreciate that there is an information gap and
try to educate the patient.
 Check that patient has a clear understanding of
the problem.
 Empathize with patient.
 Get family members involved if appropriate.
 Give time to adjust to new information.

Common Pitfalls -
 Inadequate time / information.
 Failure to elicit patient’s understanding of
situation.
 Giving news at doctor’s speed.
 Not allowing time for responses.
 False reassurances about the future.
 Allowing denial to remain.
 Removing all hope.

Lay Synonyms for Medical
Terminology
Medical Term Medical Acronym Lay Equivalent
 Cardiac arrest Code Heart stopped
Patient died
 Anoxic encephalopathy Brain damage
 Cardiopulm - resuscitation CPR Resuscitation/Reviving
 Cardiovascular Accident CVA Stroke
 Intracranial Bleed IC Bleed Stroke
 Subarachnoid hemorrhage SAH Stroke
 Myocardial infarction MI Heart attack
 Cancer/Malignancy CA Cancer
 Renal failure ARF Kidney failure
 Dialysis Kidney machine
 Respiratory failure Breathing failure
 Ventilator Vent Breathing machine
Life support

Unclear
 "Your mother has had a
severe IC bleed. She is
in the ICU and has been
intubated and ventilated.
Neurosurgery has placed
a ventriculostomy to
reduce the pressure in
her brain. We do not
anticipate a good
prognosis.”

More Clear
 "Your mother has had a
severe IC bleed. She is
in the ICU and has been
intubated and ventilated.
Neurosurgery has placed
a ventriculostomy to
reduce the pressure in
her brain. We do not
anticipate a good
prognosis.”
 "Your mother has had a
severe stroke. She is in
the intensive care unit
and has been placed on
life support. The brain
surgeons have inserted
a tube to reduce the
pressure in her brain.
We do not think she will
survive."

Communication of BBN
 Communication is a 2-way street
 Patients also have to be honest with us
regarding their symptoms, preferences, and
concerns.
 Realistic hopes and aspirations can only
be generated from honest disclosure

Key points
 Delivering bad news is an important part of
a physician's job.
 The manner in which the news is delivered
to family members will have a long lasting
effect.
 Proper training and experience will facilitate
the process.
 Remember to treat your patients as you
would like to be treated.

The Task of Breaking Bad News
“If we do it badly, the patients or
family members may never forgive
us; if we do it well, they may never
forget us.”( Buckman, 1992)

Practice makes a man.. perfect