Table of Contents
Definition of Bad News
In 1984, Buckman defined bad news as any news which influences an individual’s view of his or her future negatively and unexpectedly. Although typically “bad news” is equated with a diagnosis of a fatal disease, there are other situations which are also perceived as “bad news.”
E.g., a mother may consider the diagnosis of a psychiatric illness in her teenage son as bad news, or the diagnosis of rheumatoid arthritis in a beautiful young woman may also be considered bad news by the patient and her family. And when the diagnosis is delivered around a week prior to the young woman’s wedding, then the context changes and causes more gloom.
Importance of Breaking Bad News
The Hippocratic Oath states that a doctor should do no harm. For a physician, “breaking bad news,” besides causing personal anxiety, also can equate with causing the patient emotional harm. Until a few decades ago, physicians spared the patient the bad news and only informed their immediate family members. However, times have changed.
Studies conducted subsequent to the 1970s indicated that patients not only wanted to know about their disease but also wanted more accurate information. Hence physicians were required to break the bad news. At this time it is important to remember that there are always some patients who find bad news unpalatable and use a cloak of denial to minimize the impact of the information while continuing with the treatment.
Ethical and legal perspectives
Informed consent, patient autonomy and similar laws in most parts of the United States have mandated that physicians have an ethical and legal obligation to discuss the disease and its management with the patient unless the patient is unwilling to do so. Physicians cannot withhold information despite suspecting its adverse emotional effect on the patient.
The manner in which a physician breaks the bad news often influences the patients’ and their family’s perception of the disease, its consequences, their satisfaction with the medical care that they receive and their psychosocial adjustment. Studies indicate that physicians who are not well versed in breaking bad news can subject their patients to treatment even though the treatment is unlikely to be helpful in mitigating the outcome of the disease.
Problems When Breaking Bad News
Breaking bad news can be very stressful, especially when the patient is young, the prognosis is poor and if the physician is inexperienced. When a physician is aware that the patient and his/her family are distressed, breaking bad news can be more difficult as the physician fears the psychological consequences of imparting the information. Another important anxiety faced by the physicians is about maintaining their honesty without squashing the patients’ hopes.
Strategy for Breaking Bad News
Strategy and training can help physicians to assess the wishes of the patient and help take care of the patient’s distress when breaking the bad news. It will also help to decrease physician stress and burnout rates.
Strategies can have different mnemonics. The oncology fraternity devised “SPIKES,” which is commonly used, while the family physicians in the United States use “ABCDE” (A = advance preparation; B = build a therapeutic environment/relationship; C = communicate well; D = deal with patient and family reactions; E = encourage and validate emotions). First, we will discuss the SPIKES strategy in detail.
S = setting up
The physician should mentally prepare for the patient interview by reviewing the information, probable patient reactions and questions. Denial, negative emotions and frustration should be expected. So prepare by arranging a private interview and setting aside an adequate amount of time. Ensure that everyone in the interview room is seated. Establish rapport with the patient and his/her relatives by maintaining eye contact or holding their hand, if they are comfortable.
P = assessing the patient’s perception
Ask open-ended questions to assess the patient’s perception of their medical problem. E.g., do you remember about the procedure/surgery that you underwent last week? What do you think it was for? Or what do you know about your medical condition? From the patient’s response, the physician can determine the patient’s emotional status—whether in denial of the illness or aware of the reality.
I = obtaining patient’s invitation
While some patients may want more information, others may state that they don’t want to know, and that the physician should talk to their family members instead.
K = giving knowledge and information to the patient
The physician can warn the patient that there is some bad news. This will help the patient to mentally prepare to receive the information. Ideally, the physician should avoid using medical terminology. Instead, explain the news in layman’s (nontechnical) terms without being blunt. Provide small amounts of information at a time, and double check to make sure that the patient has understood it before proceeding further. If the prognosis is poor, do not tell the patient bluntly that “nothing more can be done.” Instead, discuss options for pain control and relief of symptoms.
E = addressing the patient’s emotions with empathic responses
Upon receiving the bad news, patients will respond by being silent or crying or denying the diagnosis or by getting angry. The physician should identify the patient’s emotions and inquire about what the patient is feeling or thinking and why they are feeling so. It is important for the physician to respond with empathy at this time, offer tissues, if necessary, and wait until the patient calms down.
S = strategy and summary
At this time, the physician can ask the patient if he/ she is ready to discuss further treatment options or plan for the future. If the patient wants to discuss at a later date or in the presence of his/her relatives, then they should be allowed to do so as it is legally mandatory but also because it assures the patient that the physician respects his/her wishes.
The ABCDE Approach in Breaking Bad News
The ABCDE approach has the following initial goals in delivering bad news:
- Allow emotional ventilation.
- Achieve a common perception of the problem.
- Address basic information needs.
- Address immediate medical risks that might be associated with breaking bad news such as suicide.
- Respond to the immediate discomforts that might be experienced after breaking the bad news to the patient.
- Ensure a basic plan for follow-up.
- Anticipate what has not been discussed yet and formulate a plan to discuss and deliver more information when needed.
- Finally, to minimize aloneness and isolation which the patient might experience after hearing the bad news.
The ABCDE technique for delivering bad news include the following strategies:
A = Advance preparation
- Ask the patient what he or she already knows about his or her condition. Enquire about their coping style.
- Arrange for the presence of a support person.
- Arrange for a time that you expect neither you nor the patient will be disturbed.
- Write down a script that you are going to use while delivering the bad news.
- Practice before seeing the patient.
B = Build a therapeutic relationship with the patient
- Ensure that the room is private and the possibility of interruptions is low.
- Provide adequate seating for the patient and his/her family members.
- Sit close to the patient. Be prepared to touch the patient if needed.
- Always reassure your patient about pain and suffering management.
C = Communicate well with your patient
- Do not be manipulative. Be direct with your patient.
- Do not use jargon medical terms.
- It is always okay to mention the words cancer and death to your patient. Just be careful how and when you will mention such a word.
- Allow for periods of silence for your patient to take it in.
- Touch the patient appropriately if needed.
- Ask the patient to repeat what you have just said to check he or she understands you.
- Arrange for additional meetings in the future for motivation and follow-ups.
- Repeat the given information if needed.
D = Deal with the patient and family reactions
- The patient might show a flight and fight response. Moreover, look for signs of withdrawal from the conversation.
- The patient might go into denial, blame, disbelief, or can accept the news. Deal with each cognitive coping mechanism appropriately.
- The patient and his or her family members might show anger, terror, anxiety, hopelessness, shame, or sadness. Assess the patient’s affective responses and deal with them appropriately.
- Allow for the patient to talk and express his or her feelings.
E = Encourage the patient to express his or her emotions
- You might tell the patient it is a good idea to involve others.
- Evaluate the effects of the news you just delivered on the patient.
- Determine the patient’s immediate, short-term, and long-term care plan.
- Refer the patient if needed.
- Arrange follow-ups.
- Provide written materials to the patient.
- Finally, assess and process your own feelings about what you have just delivered to the patient.