breaking the bad news

1. BREAKING THE BAD
NEWS
ONG JEE TAT

2. OUTLINE
1. OBJECTIVES
2. DEFINITION
3. STRATEGIES FOR BREAKING BAD NEWS
4. CLINICAL SCENERIO
5. OBSTACLES TO COMMUNICATION OF BAD NEWS
6. CONCLUSION
7. REFERENCES

3. 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

4. DEFINITION
Bad news is any news that seriously and adversely changes the patient’s view of his or her future .
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

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

8. 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

9. SPIKES PROTOCOL
The spikes strategy was developed by late Robert F Buckman , Walter F Baile and their colleagues in 1992
It centres 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).

10. SETTING
PRIVACY– find a private location such as an interview room, your office with the door closed or curtains drawn
around a bed
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 .
It also alleviates some of the stress you will experience when dealing with multiple people during an
emotionally charged interview

11. SIT DOWN
You have to be seated during an interview to break bad news
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

12. LISTENING MODE
SILENCE– this means not interrupting or overlapping the patient when he or she is talking .This
shows respect to what patient is saying.
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”

13. 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”

14. 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.

15. INVITATION/INFORMATION
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.

16. 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 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,
-Avoid technical scientific language /medical jargons much as possible
Eg: Instead of “metastasized” – say “spread”

17. • 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

18. 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.
 “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”
Avoid giving false reassurance

19. 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).

20. 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”

21. 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
Offer ongoing assistance
Possibly have a clear treatment plan in writing for the patient to take home with him

22. 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

28. OBSTACLES TO COMMUNICATION OF BAD NEWS
• Students are usually not encouraged to show emotion or feeling
• Cultural differences in disclose of ,information
• Time limitations of medical staff
• Lack of experience with issues related with death and dying
• Of not having all the answers, emotional out burst and helplessness
• No one wants to be the bad guy.
• Some families don’t want the patient to hear truth as it stands

29. IN CONCLUSION
Breaking bad news is frequently a tense and distressing experience for both the patient and the
physician.
Your patient 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
patient 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.

30. REFERENCE
1. Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Baltimore: Johns
Hopkins University Press; 1992.
2. Morris B, Abram C. Making Healthcare Decisions. The Ethical and Legal Implications of Informed
Consent in the Practitioner-Patient Relationship. Washington: United States Superintendent of
Documents; 1982: 119.
3. Meredith C, Symonds P, Webster L, Lamont D, Pyper E, Gillis CR, et al. Information needs of cancer
patients in West Scotland: cross sectional survey of patients' views. BMJ 1996; 313(7059): 724-6.
4. Doyle D, O’Connell S. Breaking bad news: Starting palliative care. J R Soc Med. 1996; 89(10): 590-1.
5. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A Six-Step Protocol for
Delivering Bad News: Application to the Patient with Cancer. Oncologist 2000; 5(4):302-11.