breaking bad news refers to sensitive process of delivering unfavourable or distressing information to patients or their families.

1. Breaking Bad News
Is it an art?
Sonam Manoj
Chairperson: Ms.
Fathima B.P

2. The biopsy confirmed her fear: inflammatory
breast cancer. Now ‘S’, a second-year clinical
Psychology trainee was called to break the
news to the patient, she had to tell her patient
the bad news. Overwhelmed and saddened by
the task, she wondered how to tell a 62-year-
old woman that she had a high risk of
recurrence, even with chemotherapy, surgery,
and radiation.

3. WHAT WHY
HOW

4. 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.

5. EXAMPLES
• Bad news is stereotypically associated with a terminal diagnosis,
• Physicians encounter many situations that involve imparting bad
news;
• for example, a pregnant woman's ultrasound verifies a fetal demise,
• a middle-aged woman's magnetic resonance imaging scan confirms
the clinical suspicion of multiple sclerosis, or
• an adolescent's polydipsia and weight loss prove to be the onset of
diabetes

6. Psychosocial context is important
• How a patient responds to bad news can be influenced by the
patient's psychosocial context.
• It might simply be a diagnosis that comes at an inopportune time,
such as unstable angina requiring angioplasty during the week of a
daughter's wedding, or
• it may be a diagnosis that is incompatible with one's employment,
such as a coarse tremor developing in a cardiovascular surgeon.

7. • Professional bicyclist Lance Armstrong's recollection of being
diagnosed with metastatic testicular cancer exemplifies the impact of
bad news on one's self-image:
“I left my house on October 2, 1996, as one person
and came home another.”
• Bad news is, therefore, a relative concept and should depend on the
patient’s interpretation of information and reaction to it.

8. WHY IS IT IMPORTANT?
• 31 October 2019: Five Goons asked two residents for their stethoscopes and upon denial snatched it and beat
them before easily escaping on motorbikes in Varanasi.
• 14 June 2019: Goons tied a doctor to a tree, gangraped his wife and robbed his money and belongings in the
Gaya district of Bihar.
• 14 June 2019: A veterinary doctor was manhandled by the owners of a Labrador dog in Kerala.
• 11 June 2019: Relatives of a 75-year old patient hurled a brick to the head of a junior resident doctor at NRS
Medical College Hospital. The doctor suffered from a skull fracture and required ICU admission.
• 5 June 2019: A Kolkata doctor was beaten up after a 6 year old boy under his care succumbed to death.
• 21 May 2019: The drunk bystanders of a patient attacked a doctor at Nizam Institute of Medical Sciences,
Telangana.
• 12 May 2019: Dikom tea garden physician was assaulted by a mob of tea garden workers in Assam.
• 27 February 2019: The grandmother of a 2-year old assaulted a junior doctor at Gandhi Hospital, Hyderabad.
• 1 January 2019: A senior pediatrician was injured at the rib and the lung by the relatives of a patient at
Hyderabad, Telangana.
• 9 February 2019: An eye-specialist on duty at Central Hospital, Digboi, Assam was assaulted by a mob

12. Remember your first experience in delivering
bad news to a patient.
Year of training?
Familiarity with
the patient?
Information
Prior planning?
Observation or
discussion of
this experience?
Did you feel you
needed more
guidance?

13. • Historically, the emphasis on the biomedical model in medical
training places more value on technical proficiency than on
communication skills.
• Therefore, physicians may feel unprepared for the intensity of
breaking bad news, or they may unjustifiably feel that they have
failed the patient.
• The cumulative effect of these factors is physician uncertainty and
discomfort, and a resultant tendency to disengage from situations in
which they are called on to break bad news.
• Rabow and McPhee keenly describe the end result, “Clinicians focus
often on relieving patients' bodily pain, less often on their
emotional distress, and seldom on their suffering.”

14. CHANGE OVER THE YEARS
• Hippocrates advised “concealing
most things from the patient while
you are attending to him. Give
necessary orders with cheerfulness
and serenity… revealing nothing of
the patient's future or present
condition. For many patients…have
taken a turn for the worse…by
forecast of what is to come.”
• In 1847, the American Medical
Association's first code of medical
ethics stated, “The life of a sick
person can be shortened not only
by the acts, but also by the words
or the manner of a physician. It is,
therefore, a sacred duty to guard
himself carefully in this respect,
and to avoid all things which have a
tendency to discourage the patient
and to depress his spirits.”

15. • In the past few decades, traditional paternalistic models of patient
care have given way to an emphasis on patient autonomy and
empowerment.
• A review of studies on patient preferences regarding disclosure of a
terminal diagnosis found that 50 to 90 percent of patients desired full
disclosure.
• Because a sizable minority of patients still may not want full
disclosure, the physician needs to ascertain how the patient would
like to have bad news addressed.
• Therefore, the physician faces the challenge of individualizing the
manner of breaking bad news and the content delivered, according to
the patient's desires or needs.

16. WHY IS IT DIFFICULT?
PATIENT’S
PERSPECTIVE
CLINICIAN’S
PERSPECTIVE

17. The Patient’s Perspective
• Patients often have vivid memories of receiving bad news.
• Negative experiences can have lasting effects leading to anxiety and
depression
• lack of security.
• They often look for reassurance from the doctor.
• Patients may sense a loss of control and be overwhelmed with
uncertainty, particularly if their prognosis is unclear.
• Can facilitate adaptation to illness and deepen the patient-doctor
relationship

18. 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.

19. How Should Bad News Be Delivered?
• 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
• The recommendations are intended to serve as a general guide and
should not be viewed as overly prescriptive.

20. SPIKES PROTOCOL
• SETTING up Interview
S
• Assessing the Patient’s PERCEPTION
P
• Obtaining the Patient’s INVITATION
I
• Giving KNOWLEDGE and information
K
• Addressing the Patient’s EMOTIONS
E
• STRATEGY and SUMMARY
S

21. S – SETTING up Interview
• Mental rehearsal
• Environment
• Sit down, same eye level
• Make a connection with the patient
• Allow uninterrupted time in initial
meeting
• Arrange for a second appointment

22. P – Assessing the Patient’s PERCEPTION
• “Before you tell, ask”
• “what do you know about your condition so far?”
Denial/ unrealistic expectations/ lack of education/ superstitions
• “could you tell me what you are hoping for? That will help me do a
better job for you”

23. I – Obtaining the Patient’s INVITATION
• 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.
• Do NOT overwhelm the patient with information, but instead give it
in small chunks at a time.
• Denial is a coping mechanism and clinicians should be prepared to
accept that it is often an appropriate response to bad news

24. K – Giving KNOWLEDGE and Information
• 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

25. DOs
• “the test results just came back
and we’re not too happy about
it,” or
• “your chest X-ray doesn’t look
very good.”
DON’Ts
• “you have breast cancer and
unless you get treatment you
will die”
• “nothing can be done”

26. Lay Synonyms for Medical Terminology
• Cardiac arrest - Heart stopped and the Patient died
• Anoxic encephalopathy - Brain damage
• Cardiopulmonary – resuscitation/ CPR -Resuscitation/Reviving
• Cardiovascular Accident - Stroke
• Intracranial Bleed- Stroke
• Subarachnoid hemorrhage – Stroke
• Myocardial infarction - Heart attack
• Malignancy - Cancer
• Renal failure -Kidney failure
• Respiratory failure - Breathing failure
• Sepsis- infection spread to blood
• Ventilator - Breathing machine Life support

27. 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.”
CLEARER
"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."

28. E – Addressing the Patient’s EMOTIONS
with Empathic Responses
• 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

29. Response to Reaction
• If patient 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 patient is Angry
• Defensive or irritation with patient are unhelpful.
• Acknowledge patient’s position and avoid talking about it.

30. • If patient refuses to accept the 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. ν Empathize
with patient.
• Get family members involved if appropriate.
• Give time to adjust to new information

31. S – 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

32. SPIKES PROTOCOL
• SETTING up Interview
S
• Assessing the Patient’s PERCEPTION
P
• Obtaining the Patient’s INVITATION
I
• Giving KNOWLEDGE and information
K
• Addressing the Patient’s EMOTIONS
E
• STRATEGY and SUMMARY
S

33. 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.

34. SEVEN PROMISES A PHYSICIAN SHOUD MAKE TO THE
DYING PATIENT- Mitka M JAMA, 2000
1. You will have the best medical treatment, aiming to prevent
exacerbation, to improve functioning and to ensure comfort.
2. You will never have to endure overwhelming pain, shortness of
breath, or other symptoms.
3. Your care will be continuous, coordinated and comprehensive.
4. You and your family will be prepared for everything that is likely to
happen in the course of your illness.
5. Your wishes will be sought, respected and followed whenever
possible.

35. 6. We will consider your personal and financial resources, and we will
respect your choices about their use.
7. We will do all that we can to see that you and your family will have
the opportunity to make the best of every day.

36. IF DONE RIGHT
• 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.

37. Further reading

38. CONCLUSION
• 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.

40. THANK YOU