Breaking bad news in clinical practice is a complex task that one is faced with constantly and needs some level of skills

1. BREAKING BAD NEWS
DR OGECHUKWU MBANU
DEPARTMENT OF FAMILY
MEDICINE
AKTH
16-03-2017

3. PRE- TEST
1. The following are protocols for breaking bad news
except
A. SPIKES
B. CONES
C. ABCDE
D. CLASS
E. BREAKS

4. 2. Which of the following may family members
express at the time of being given a bad news
A. anger
B. Denial
C. Relief
D. Blame
E. All of the above

5. 3. Which of the following should never be used
when breaking bad news
A. Compassion
B. Professional jargons
C. Appropriate body language
D. Touch
E. Cautious optimism.

6. 4. Which of the following is not routinely
involved in breaking bad news
A. Respond to patients feeling
B. Tell the family
C. Find out what patient knows
D. Start with a warning shot
E. Listen attentively

7. 5. The “s” of the SPIKES protocol of breaking
bad news stands for
A. Setting up the interview and suspending
medical jargons
B. Setting up the interview and “strategy and
summary”
C. Sitting the patient down and “strategy and
summary”
D. Sitting the patient down and suspending
medical jargons.
E. Set eye on the patient and sit near patient

8. 6. Which of the following is important to ensure in
preparing to break bad news
A. An appropriate comfortable environment
B. Privacy
C. Good knowledge of patients medical history and
history of medical problem
D. A lack or minimal interruptions or distractions
E. All of the above

9. OUTLINE
1. OBJECTIVES
2. INTRODUCTION
3. DEFINITION
4. STRATEGIES FOR BREAKING BAD NEWS.
5. THE ANGRY PATIENT.
6. BREAKING BAD NEWS OVER THE PHONE.
7. OBSTACLES TO COMMUNICATION OF BAD NEWS .
8. WORDS TO AVOID.
9. ROLE OF FAMILY PHYSICIAN AS APPLIED TO
BREAKING BAD NEWS .
10. CONCLUSION.
11. REFERENCES.
12. CLINICAL SCENERIO.

10. OBJECTIVES
1. .To understand what constitutes a bad news.
2. To discuss some strategies for breaking bad news in
medical practice
3. To identify obstacles to communication of bad news.
4. To be able to use an organized approach in the
communication of bad news.
5. To become aware of what to do and what not to do
on breaking bad news to patients

11. INTRODUCTION
 Studies show that discussions of bad news do not meet
patients needs and fall short of expert recommendations
 Patients with cancer tend to disclose fewer than 50% of their
concerns because of inability to communicate with their
physician
 Physicians predictions of their patients wishes regarding end
of life care and life sustaining treatments were closer to their
own choices than based on the patients expressed wishes
 Patients generally(50-90%)desire full and frank disclosure;
though a sizeable minority still may not want the disclosure

12. DEFINITION
 Bad news is any news that seriously and adversely changes the
patient’s view of his or her future .
 It can also be seen as diagnosis that comes at an inopportune
time e.g. coarse tremor developing in a cardiovascular surgeon
 A situation where there is either a feeling of no hope, a threat
to one’s mental or physical well– being ,a risk of upsetting an
established lifestyle, or where the message given conveys
fewer choices in his or her life
 SLAI – Sharing life altering information

13.  It can can be seen as the gap between the patients expectations
and the reality of the patients medical condition. E.g.
1. News of a degenerative disorder (Parkinson's
disease),cancer ,metabolic diseases
2. Intrauterine fetal death
3. Failure of medications, radiotherapy or poor prognosis e.g.
metastasis, resistance or a relapse etc
4. News that threatens a patients means of livelihood e.g.
amputation of limb of an athlete or surgeon or any body at
all
5. Medical error to patient and family members
6. Diagnosis of serious sexually transmitted disease such as
HIV

15.  Strategies for breaking bad news
 Different strategies have been applied by
doctors and these includes
1. SPIKES
2. ABCDE
3. BREAKS
4. CONES
 SPIKES and ABCDE appear to be the most
commonly used

16. ABCDE strategy
 A = Advance preparation
 B= Build a therapeutic
environment/relationship
 C= Communicate well
 D= Deal with patients and family reactions
 E= Encourage and validate emotions.

17. •A– Advanced preparation
 Familiarize yourself with the relevant clinical in
formation e.g. investigations ,hospital report etc
 Arrange for adequate time and privacy comfortable
environment
 Instruct staff not to interrupt
 Be prepared to provide at least basic information
about progress and treatment options (read it up if
need be)
 Mentally rehearse how will deliver the news
 Script specific words and phrases to use or to avoid
 Know your patient well so that you will be speaking
to the patient not the diagnosis

18. B-- Build A Therapeutic Environment/
Relationship
 Introduce yourself to the patient and everyone present
 Determine patient preferences for what and how much he/she
wants to know
 Summarize what has happened to date, check with patient
/relative .
 Discover what has happened since last seen .Judge how the
patient is feeling or thinking
 Give a warning shot “I am afraid it looks more serious than we
had hopped it would be”
 Use touch when appropriate
 Pay attention to verbal and non verbal cues
 Avoid inappropriate humor
 Assure patient that you will be available

19. C-- Communicate Well
 Speak frankly but with compassion
 Determine the patients knowledge and understanding
of the situation
 Proceed at the patients pace
 Avoid medical jargons
 Allow for silence and tears
 Have patient describe his /her understanding of the
information given
 Encourage and answer questions
 Provide written /drawn information to encourage
Understanding and remembrance

20. D-- Deal With Patient And Family Reactions
 Assess and respond to emotional reactions
 Be empathetic
 Be aware of cognitive coping strategies e.g.
1.Denial
2.Blame
3.Disbelief
4.Guilt
5.Acceptance
 Assess for despondency and suicidal ideations
 Allow for “shut down” when patients turn off and stops
listening
 If you cry it is not inappropriate but be able to put it under
control
 Don’t argue with or criticize colleagues .Avoid defensiveness
regarding your or a colleagues medical care

21. E-- Encourage And Validate Emotions.
 Offer realistic hopes and encouragement about what
options are available
 Explore what the news means to the patient
 Discuss treatment options
 Use multidisciplinary services e.g. hospice care,
spiritual leader

22. SPIKES PROTOCOL
 The spikes strategy was developed by late Robert F
Buckman , Walter F Baile and their colleagues in
1992
 It centers on defining the central element of the bad
news ,that is what makes it bad news to the patient
and addressing it as well as acknowledging patients
concerns and emotions
 S-- Setting up the conversation
 P-- Perception
 I-- Invitation by the patient (Involving the patient)
 K-- Knowledge to the patient
 E-- Emotions and Empathy
 S-- Strategy and summary + (Self reflection).

23. SETTING
 PRIVACY– find a private location such as an interview room, your office
with the door closed or curtains drawn around a bed
 Ask the patients permission to turn off the TV or the radio to minimize
distraction
 Where the news is broken can have significant effect on the outcome of the
interview
 INVOLVE SIGNIFICANT OTHERS—
 Some patients may or may not like to have family members or friends
around with them
 If there are a number of people closely supporting the patient ask your
patient who will act as a spokesperson for everybody during the discussion
 This gives your patient support
 It also alleviates some of the stress you will experience when dealing with
multiple people during an emotionally charged interview
 SIT DOWN
 You have to be seated during an interview to break bad news
 Avoid sitting behind barriers

24.  If patient is in a hospital bed pull up a chair or if there is no sit ask permission
to sit on the edge of the bed
 Being seated lessons the intimidating visual impact of the doctor towering over
the patient ,which can make patient feel uncomfortable
 LOOK ATTENTIVE AND CALM
 Maintain eye contact. this assures patient that you are listening
 If you are fidgety ,you can adopt the ‘psychotherapy neutral position’. This is
simple matter of placing you feet flat on the floor and your ankles together and
putting your hands ,palms downward on you laps
 If the patient becomes tearful ,is a good idea to break eye contact momentarily
 LISTENING MODE
 This involves
1. SILENCE– this means not interrupting or overlapping the patient when he or
she is talking .This shows respect to what patient is saying.
2. REPETITION– Repetition involves using the most important word from the
patient’s last sentence in your first sentence,
e.g.. Patient : I am fed up with this treatment
Doctor :Which aspect of the treatment makes you fed up.
 Nodding
 Smiling ( appropriately)
 Saying things like “HMMM”

25. • AVAILABILTY
• Make arrangement for the phones to be answered by
other staff members or voice mail.
 Make sure staff members do not interrupt the
meeting.
 If however unavoidable phone calls or interrupting do
occur, courteously address them so that your patient
doesn’t feel less important than the interruption.

26. P --PERCEPTION
 Assess the patients understanding or the seriousness of their condition.
 Ask what the patient and family already know
 “Tell me what you understand about your condition so far”
 “what did you think was going on with you when you felt the lump”
 Assess the patient and family members level of understanding.
 Take note of discrepancies in the patient’s understanding and what is
actually true. Correct misinformation if possible.
 Watch for signs of denial. it is often helpful not to confront the denial
at the first interview. Denial is an unconscious mechanism that may
facilitate coping and should be treated gently over subsequent
interviews(if time permits)
 Confrontation of denial out rightly may raise anxiety unnecessarily or
even set up an adversarial or antagonistic relationship.

27. • I-- INVITATION/INFORMATION
 This step is center of “the before you tell, ask”
principle
 Although most patient want to know all the details about their
medical situation, you can’t always assume that is the case.
 Obtaining overt permission respects the patients right to know
(or not to know).
 Accept the patient right not to want to know, but offer to
answer any question he or she have later eg
 “How much information would you like me to give you about
your diagnosis and treatment.”
 “ would you like me to give you details of what is going on or
would you prefer that I just tell you about the treatment I am
proposing.”
 Offer to answer any questions the patient/ family members
may have.

28. K—KNOWLEDGE
EXPLAINING THE FACTS
 Before you break bad news, give your patient a warning that bad news is coming.
 This gives your patient a few seconds longer to prepare psychologically for the bad
news.eg
 “Unfortunately, I ve got some bad news to tell you”
“it looks like the result is not very good”
Use the same language as your patient when giving your patient bad news, this involve
aligning or matching terminology with patient,
 Patient speaks pigeon English, try a bit of it
 Avoid technical scientific language as much as possible eg
 Instead of “metastasized” – say “spread”
 Give information in chunks and clarify that the patient understands what you have
said at the end of each chunk.
For example
 “ Do you see what I mean”
 “ Are you with me so far”
 Avoid being pessimistic, over optimistic but tell the whole truth

29. E-- EMPATHY AND EMOTION
Have an emphatic response to patients problem, the emphatic response
is a technique or skill , not a feeling,.
 Acknowledge patients emotions as they arise and address them.
 The emphatic responses comprises of 3 straight forward steps.
 Step 1 : listen for and identify the emotion (or mixture of emotion)
 Step 2 : Identify the cause or source of the emotion, most likely the
bad news the patient received
 Step 3: Show your patient that you have made the connection between
the above two steps, that is that you have identify the emotion and its
origin.eg
 “Hearing the result of the bone scan is clearly a major shock to you”
 “Obviously this piece of news is very upsetting”
 Validate or normalize the response, you might use such phrase as,
 “I can understand how you can feel that way”
 “I think your anger is a very normal response in the circumstance”

30. TYPES OF EMPATHY EXPRESSION
NON VERBAL EXPRESSION OF EMPATHY
 Maintain Eye contact
 Sit down close and face the patient
 Have an Open body posture ,with no obstacles between you and the patient.
 Be Relaxed without any tension
 Touch (be mindful to touch neutral parts of the body e.g.. Arms, and pay attention
to see if patient does or does not appreciate it, pay attention to cultural of
religions inclinations).
VERBAL EXPRSSION OF EMPATHY (the NURSE acronym)
 N – Name the emotion
 “you seem angry”
 U – Understand/normalize the emotion
 “this must be hard and difficult”
 R– Respect the patient and family for how they are coping
 “ I really am impressed at how much you care for…….
 S– Support the patient so they don’t feel alone
 “our team will be here”
 E– Explore the emotion further, “tell me more about why you feel this way”

31. • SOME EMOTIONAL REACTIONS FROM
PATIENT
 In an emotionally charged scenario, it is very often helpful
to address the emotional first and the issue second.
 This makes patient feel that he or she has been listening to
and heard, it is an important component of support
 CRYING – Crying is a symptom , it usually express
distress, pain or anger (But also joy).
 Offer tissue if it is available
 Remember to break eye contact momentarily – no one like
to be seen crying because he or she feels particularly
vulnerable.
 DENIALS - “It is not me , the lab must have mixed up the
specimen”
 ANGER - “ Why was this not seen earlier”
 NUMBNESS

32. S--STRATEGY AND SUMMARY
STRATEGY
Decide what the best medical plan would be for the patient.
Recommend a strategy on how to proceed .
Ask the patient to repeat to you their understanding of the plan
Possibly have a clear treatment plan in writing for the patient to take
home with him
SUMMARY
 Summarize the conversation
 Focus on your goals
 Offer to answer questions (be prepared for tough questions)
 Explore patients agenda (ICE)
 Ideas – what may help
 Concerns – what is worrying them
 Expectations – what are their hope for the future
 Assure the patient that you will be available as well as your team to
offer any help possible

33. • BREAKS
• Put together by Drs Narayanam, Bista and Koshy all from India
 B – Background - In depths knowledge of the patients problem
 R – Rapport - The physician should establish a good rapport
with the patient.
 E – Exploring - Find out what patient ,knows about the illness,
identify potential conflicts between the patients belief and the
diagnosis, if patient allows you, involve significant others
 A - Announce - Give a warning, short information should be
given in easily comprehensive sentences , a useful rule of thumbs is
not to give more than three pieces of information at a time.
 K – Kindling - Observe patient’s response, his or her
emotional reaction and kindle the emotion.
 S – Summarize – Summarize just as in the SPIKES
strategy

34. THE CONE PROTOCOL
Used in the following situations
1. Disclosing a medical error
2. Sudden deterioration in the patients medical condition
3. Sudden unexpected death
Note:
The news should be delivered by the most senior person on
the patients treatment team.
C - Context
O - Opening Slot
N – Narrative
E – Emotions
S – Strategy and summary

35. C –CONTEXT
 Prepare for what to say and anticipate the patient family
reaction.
 Have the conversation in a quiet undisturbed area
 Seat the patient closest to you and have no barriers between
you
 Have a box of tissues available.
O – OPENING SLOT
 Alert the patient /family members of the impending bad
news,
 “ this is difficult, I have to tell you what I found out about
why your mother is so ill”
 “ I must talk to you about your condition”

36. N – NARRATIVE APPROACH
 Explain the chorological sequence of events
 “ as you know your mother came back in……….”
 “ then we gave her ………. and there was little improvement”
 “ last night we ………… and I just found out that …….. in order words, she received
too much chemotherapy”
 Avoid assigning blame and or making excuses
 Emphasize that you are investigating how the error occurred
 OFFER A CLEAR APOLOGY
E – EMOTIONS
 Address strong emotions with empathic responses
 Use the E – V – E protocol as soon as emotions occurs
(EXPLOE,VALIDATE,EMPATHIZE)
 “ I know that it is upsetting for you and it is awful for me too”
 “ I know this is awful”
 “ it’s very rare, but it does happen and I am sorry to say that it did”
 Beware of being pushed into making promises you cant deliver
 Avoid reassuring the person that there is going to be a good outcome or that no harm
was done.

37. THE ANGRY PATIENT
• WHAT TO DO
 Acknowledge the person’s anger
 Try to find out the reason for his anger e.g.. Frustration , fear or guilt.
 Validate his feelings
 Let him ventilate his anger or any feeling that led to the anger.
 Offer to do something or for him to do something.
HOW TO DO IT
 Sit reasonable close to patient ( not too close, not too far),and maintain eye
contact
 Speak calmly without raising your voice
 Avoid dismissive or threatening body language
 Be empathetic
 be aware of your safety
• WHAT NOT TO DO
 Glare at the person
 Confront, interrupt or touch him or her
 Put the blame on others or seek to exonerate yourself
 Make unreasonable promise

38. BREAKING BADNEWS OVER THE TELEPHONE
THIS SHOULD BE AVOIDED AS MUCH AS POSSIBLE UNTIL IT
BECOMES ABSOLUTELY NECESSARY.
 Balance the need to provide basic information about the situation
while avoiding extended counseling during the initial moments of
shock
Some patient may accept a brief phone conversation with the
initial statement of bad news , a statement of sympathy, and a
follow up plan.
Some patients may attempt to take control of the situation (and
their grief / pain) by trying to ask too many question.
Acknowledge the difficulty of waiting for a follow up
appointment for extended discussion
 Gently , but firmly limit the extent of conversation.

39. NO NEWS IS NOT
GOOD NEWS IT IS AN
INVITATION TO FEAR
C M FLETCHER.

40. 
OBSTACLES TO COMMUNICATION OF BAD NEWS
Medical education doesn’t teach it well enough
 Students are usually not encouraged to show emotion or feeling
 There is Unrealistic expectation of the healthcare system by society
 Cultural differences in disclose of ,information
 Time limitations of medical staff
 lack of trust in the medical system
 lack of experience with issues related with death and dying
1. Emotions such as Fear of the process of dying, of blame, of not having all the
answers, emotional out burst
 Sadness ,guilt ,failure, helplessness
 No one wants to be the bad guy.
 Some families don’t want the patient to hear truth as it stands”
 some doctors feel it is a waste of their precious time so spend as little time as
possible doing it
 Multiple physicians - who should perform the task.
 Fear of medico – legal system - everyone has a “right” to be cured : if no cure
happens, someone is to blame.

41. WORDS TO AVOID.
 “ I cant care for you anymore” you may mean well in terms of
wanting to refer to a specialist but say it in a better way
 “ there is no more hope” there can always be a shifting of hope NOT
NO HOPE
 “ It is time for us to stop treatment”(what about pain and palliative
drugs)
 “ There is nothing more we can do for you” There is always
something that can be done e.g. pain management ,periodic tapping of
ascitic fluid, yoga.etc
 “ Instead of saying “I am sorry” you may say “I wish things were
different”
 Do not say “we are going to stop the machine or pull the plug”
REMMEMBER TO GET HELP --- patients care may involve :
 Multidisciplinary team (call members)
 Spiritual help (spiritual leader to patient)
 Behavioral medicine experts, palliative care consultation
 Medical Ethics team of the hospital should be involved

42. Importance of protocols
 Fear
 Lack of training
 Lack of confidence
 Improve experience for family and patient and also the doctor.

43. THE ROLE OF THE FAMILY PHYSICIAN
 The family physician is a six star physician ,playing
the role of the patients :
1. Care giver
2. Coordinator
3. Communicator
4. Advocate
5. Resource manager
6. Researcher

44.  The family physician is the first contact person serving as port
of entry into the health care system and comitted to patient
centered comprehensive care.
 He or she serves a coordinative function for the patient by
involving relevant medical/ paramedical colleagues to help
patient deal with patients medical issues.
 Coordinates referrals and translates special advice and
feedback.
 The family physician uses every opportunity for health
promotion preventive care ,patient education and
rehabilitation.
 Explores the FEARS,IDEAS,EFFECT ON
FUNCTION,AND EXPECTATIONS of the patient (FIFE).
 He or she is the advocate 1) defining what is needed to help
patient with due regard to cost effectiveness. 2)assessment of
impact of health condition on the family.3) identifying with
values and beliefs of the patient.

45.  He is the resource manager helping in the Human, Financial,
Material, Time management(the 4 M’s)
 Involvement in ongoing research bringing interesting or new
findings to the lime light. Research continues in the area of
breaking of bad news, effects on patient ,family and the doctor.

46. IN CONCLUSION
Breaking bad news is frequently a tense and distressing
experience for both the patient and the physician.
 Your patients emotional responses will be difficult to
withstand unless you have a strategy with which to address
them, note that more than 50% of communication of bad
news is non verbal, focus on the patients concerns.
 Know the facts (patient details, expectations, culture,
religious inclinations)
 Acknowledge the limitations of a physician and medical
science in general
 Finally practice communicating clearly, completely and
compassionately.
..

47. • REFERENCE
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49. CLINICAL SCENARIO
A 54 year old lady attends your clinic to find out the
result of an MRI of her spine, she has had constant
pain all over her spine for the last 2months, she also
has a history of breast cancer which was treated
5years ago.
 Her report shows that she has some secondaries all
over her spine
 Proceed with this consultation to tell her the
findings of the MRI
 Spikes.

50. •
THANK YOU FOR YOUR TIME