Delivery of Bad News

At some point in their careers, all physicians will have to deliver bad news to patients and/or their families. While this is a difficult and sensitive subject, there are communication techniques and protocols that can assist physicians in delivering bad news in a way that maintains and even strengthens the physician–patient relationship.

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Overview

Bad news is broadly defined as any information that may alter a patient’s view of their future. Bad news is typically life-changing information that should be communicated to the patient and family with empathy and honesty.

Effects on patient and families

  • Changed vision of the future; need to alter established lifestyle
  • Social stigma and/or impact of the particular diagnosis or treatment
  • Lack of hope
  • Perception of decreased options in life
  • Financial/practical concerns regarding new diagnosis or treatment

Difficulties for physicians

  • Worry about effects of the news on the patient (e.g., depression)
  • Fear of the patient’s reaction; uncertainty about how to handle the patient’s emotional response
  • Fear of being blamed or challenged
  • Fear of not having “all the answers”
  • The interaction may cause stress that affects interactions with other patients, colleagues, or their own family

Most common types of bad news

  • New diagnosis:
    • Chronic disease (e.g., diabetes mellitus)
    • Progressive illness (e.g., multiple sclerosis)
    • Fatal disease (e.g., Huntington disease)
    • Disease impacting fertility (e.g., premature ovarian insufficiency)
  • Scope of injury (e.g., season-ending knee injury)
  • Disease recurrence or progression despite treatment (e.g., cancer)
  • Critical condition or death of a family member

Setting and timing

  • Quiet and private setting; never with other patients or in a place where one can be overheard.
  • An adequate amount of time must be allocated for discussion. Do not rush the encounter. 
  • A relative, clergy person, psychologist, and/or social worker may be present to support the patient.

General content and manner of delivery

  • All relevant information regarding diagnosis, prognosis, alternative treatments, and complications should be discussed with the patient:
    • Never lie to patients!
    • The amount of information should be reasonable.
    • The amount of information patients want to receive varies by culture, education level, age, and sex (e.g., studies indicate that younger, female, and more highly educated patients tend to prefer more detailed information).
  • News should be delivered in a sensitive, patient, empathetic, and professional manner.
  • Patients should be given information about where to find support after the discussion ends:
    • Informational pamphlets, websites, or other resources
    • Support groups or hotlines
    • Easy ways to contact someone for questions/concerns that arise after the discussion
  • The patient needs to be allowed to process the information at their own pace. 
  • The clinician must be aware of proper wording and their own body language.
  • The clinician must be attentive to the patient’s verbal and nonverbal responses to know when it’s appropriate to pause.

Protocols for Delivering Bad News

Overview

No one model or method is perfect, though each protocol provides a loose structure for delivering bad news in an effective, compassionate way.  Mnemonics are used for 3 of the most common protocols, though they share many of the same concepts (which are detailed in the subsequent subsections):

  • SPIKES protocol:
    • Setting
    • Perception
    • Invitation
    • Knowledge
    • Emotions
    • Summary and Strategy
  • ABCDE protocol
    • Advanced preparation
    • Build a therapeutic environment/relationship
    • Communicate well
    • Deal with patient and family reactions
    • Encourage and validate emotions
  • BREAKS protocol:
    • Background
    • Rapport
    • Explore
    • Announce
    • Kindle 
    • Summarize

Concept: advanced preparation/background

  • Know the patient’s clinical history and background.
  • Mentally rehearse and emotionally prepare for the interaction.

Concept: setting/therapeutic environment/rapport

  • Delivery of bad news should always be in person, if possible.
  • Accompanied by family members, as the patient desires
  • Obtain consent to deliver the information in front of other people (e.g., “We are going to talk about something very sensitive. Do you want them to be present?”).
  • Private and separate room:
    • Tissues available
    • Seating for everyone
  • Avoid interruptions (e.g., silence pagers).
  • The clinician should keep a tranquil demeanor.
  • Management of body language:
    • Focus on the patient.
    • Maintain appropriate eye contact (avoid charting during discussion).
    • Nonverbal indicators of interest in the patient

Concept: perception/explore

  • Assess the patient’s understanding of the situation.
  • Use open-ended questions to gauge the patient’s understanding.
  • Correct misinformation and misunderstandings.
  • Identify wishful thinking, unrealistic expectations, or denial. 
  • Pay attention to the patient’s answers: The patient will communicate, in one way or another, emotional content associated to their current state (e.g., hope, despair, indifference).

Concept: invitation

  • Ask the patient how much detail they desire to know.
    • Do they prefer to know all the details or to focus on the most important result?
    • A competent patient has the right to not know every detail; in these cases, the invitation for more information must be made clear to the patient/family.
  • Ask permission to give results:
    • Lets the patient control the conversation
    • For example, “Would it be okay if I review your biopsy results now?”
    • Patient may prefer to have family/support person present, so may prefer to wait to receive results (and this wish should be respected).

Concept: knowledge/communicate/announce

  • Summarize events in a clear, stepwise fashion.
  • Stop often to confirm understanding.
  • Avoid technical language or jargon.
    • Use plain, simple language in the patient’s native language.
    • Use a professional medical interpreter when necessary; do not deliver bad news through an interpreting family member.
  • Reinforce important key points.
  • Answer every question.
  • Alignment: Explain the information in a way that aligns the patient’s understanding with reality.

Concepts: emotions/reactions/kindle

  • Address emotions as they arise.
    • Look for adaptive and/or maladaptive emotions:
      • Humor/guilt
      • Sadness/despair
      • Realistic hope/unrealistic hope
    • Try to identify why patients are experiencing the emotions they are feeling.
  • Use empathetic statements to recognize the patient’s emotion.
  • Validate patient responses; reassure patients that their opinions are being heard and will be respected.
  • Ask open-ended questions to clarify emotions when they are not obvious.
  • Ask about emotional and spiritual needs and support systems (the clinician should not shy away from asking about religion). 
  • Offer realistic hope without setting false expectations.
    • Excessive reassurance may create false expectations.
    • Identify and reinforce coping strategies.
  • Be aware of your own wellness during and after delivery of bad news. 
  • It is okay to show your own emotions. 
  • Never criticize other colleagues and do not become defensive about your or the colleague’s medical care.

Concepts: strategy/summary

  • Summarize the important points.
  • Set a clear plan for the patient’s next steps, which may include referrals, additional testing, and treatment options.
  • Provide patients with contact information in case additional questions arise.
  • Provide the patient with support resources, for example: 
    • Support group
    • Educational websites
    • Contact hospital religious services if available/desired

Summary of different protocols for delivering bad news

Table: Different protocols for delivering bad news
ConceptSPIKES protocol terminologyABCDE protocol terminologyBREAKS protocol terminology
Know the patient’s history and background.CNIAdvanced preparationBackground
Quiet location, adequate time for discussion, support person present, ask for permission to deliver the newsSetting invitationBuild a therapeutic environment.Rapport
Assess what the patient understands about their condition.PerceptionAdvanced preparationExplore
Deliver the news.KnowledgeCommunicateAnnounce
Address emotions as they arise.Emotions
  • Deal with patient and family reactions.
  • Encourage and validate emotions.
Kindle
Summarize and form a plan going forward.Summary and strategyCNISummarize
CNI: concept not included in this protocol

References

  1. Have, H., Gordijn, B. (2013). Handbook of global bioethics. Dordrecht, the Netherlands: SpringerReference. 
  2. Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., Kudelka, A. P. (2000). SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. The Oncologist 5:302–311. https://doi.org/10.1634/theoncologist.5-4-302.
  3. VandeKieft G. K. (2001). Breaking bad news. American Family Physician 64:1975–1978.
  4. Berkey, F.J., Wiedemer, J.P., Vithalani, N.D. (2018). Delivering bad or life-altering news. American Family Physician 98:99–104. Retrieved July 6, 2021, from https://www.aafp.org/afp/2018/0715/p99.html.

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