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Breaking bad news
Professional skills
Breaking bad news
Relevance to the curriculum
Sarah L Greening
4.0 Relationship with patients and communication skills (ii) Breaking bad news
nature, the patient’s emotions and reactions are very likely to be completely different to your own. Setting • Organize privacy – preferably in a separate room. • Ensure chairs are available so that everyone present can sit down. • Ensure that the time is protected – if necessary, ask a colleague to hold your bleep so that there are no interruptions.
Breaking bad news to a patient may be viewed as one of the most difficult areas within the job of a doctor. Bad news may be defined in a variety of ways, including ‘any information which adversely and seriously affects a patient’s view of his or her future’.1 Examples of bad news include: • telling a patient that they have cancer • telling a patient that they are HIV positive • telling a couple that they cannot have children • telling a spouse that their husband/wife has Alzheimer’s. The result of any bad news is that the patient’s perspective on their future will alter irrevocably, potentially resulting in a very different future and lifestyle. It is acknowledged within many studies that the way in which the news is given by the doctor has a major impact on the patient, so it is important that the information is conveyed in the most appropriate manner. Bad news should be given directly to the patient, unless the patient has expressly instructed that the information is given to a family member, or the patient has impaired understanding due to a psychiatric disorder, confusion or altered levels of consciousness. Sensitivity, dignity and respect are paramount and the information must be shared in a way that is acceptable and understood, with minimum risk of future problems such as collusion.2
Patient • Check whether the patient requires a family member or close friend to be present at the interview. • If English is not the patient’s first language, ensure that the appropriate translation service is available. • If the patient has problems with hearing, ensure that facilities are available to reduce the impact of this, for example, the hearing aid is in the patient’s ear!
The interview It is important to start by checking with the patient what their current perceptions are, and to discover what has happened since you last saw them. This will provide you with the opportunity to judge how the patient is feeling and allow you to gauge how much the patient wants to know.3 This is extremely important, as there are patients who choose to remain ignorant of bad news as this is key to their coping mechanisms. A patient’s refusal of offered information is a form of personal care that protects the individual from threat to self.4 Bear in mind that it is not necessarily permanent, and the offer of information will need to be repeated in the future to provide the opportunity for a change of mind. On the other hand, you may be surprised by the detail that the patient is already aware of.
Preparation Preparation for the interview with the patient can be seen in three parts. Yourself • Familiarize yourself with the patient’s records, so that you are aware of the history and investigations up to this point. During this familiarization, consider questions that the patient may ask that link to the progress to date. • Rehearse the discussion either on your own or with a colleague. • Arrange for a colleague such as a member of the nursing team to be present for the interview. • Consider your own feelings and emotions about the case in order to set them to one side as much as possible. Bear in mind that even if you have had personal experience of a similar clinical
Providing information Provide a warning that the news is going to be bad. The use of phrases such as “I’m afraid that it looks more serious than we had hoped….” can be useful at this point. Then provide the basic information in a simple, straightforward and honest way. Avoid the use of jargon and repeat important points. Although you may feel uncomfortable sharing the information, remember to provide small chunks of information at a time and check the patient’s understanding. Avoid the use of terms like “There is nothing more that we can do…” as there will be plenty more that can be offered, for example, in terms of palliative care – symptom control and emotional support. Allow the patient the opportunity to ask questions at various points of the interview. Don’t avoid questions because you may not know the answers. If you do not know the answer, then offer to ask another member of the team. Avoid using specifics in terms of timeframes – it is reasonable to talk in prognostic terms
Sarah L Greening MB ChB MRCGP DRCOG is a General Practitioner and GP Trainer at Langham Place Surgery in Northampton, UK. She qualified from Leicester and completed Vocational Training in Kettering. Her clinical interests include women’s health and palliative medicine. Conflict of interests: none declared.
THE FOUNDATION YEARS 4:4
162
© 2008 Elsevier Ltd. All rights reserved.
Professional skills of weeks or months or years but if you add a figure to the timeframe at this time it may well be incorrect and the patient is likely to recall this figure as one of the key facts of the interview. Time within the interview is extremely important as each patient will react differently to the information that you are providing. Also, be prepared to come back to the patient on another occasion to repeat the information in order to improve clarification. During the interview, it is important to offer to speak to members of the patient’s family, with the patient’s consent, as the patient may perceive this as quite a burden.
It is important to identify support mechanisms for the patients such as friends and family. You may then repeat the offer to speak to others on the patient’s behalf. This is also a good time to make written materials available for the patient (and family) to peruse at their leisure. Documentation It is vital to communicate with the rest of the team after the interview. This includes the patient’s GP if you are working within secondary care, as it is the GP who will have further conversations with the patient following discharge. It also allows others to identify any levels of denial that the patient has. Document key details of the conversation in the patient’s notes and if you are sending a letter, include notes of the conversation in the letter. Consider offering a copy of this letter to the patient as he/she may find it a useful tool particularly when talking to other family members and close friends.
Support During the interview, monitor the patient’s emotions using both verbal and non-verbal clues and cues. Acknowledge their feelings but avoid using the term “I know how you feel”, as even if you have had a similar personal experience your emotions and feelings are likely to be very different to those of the patient. The use of a phrase such as “I can understand how difficult this must be for you” does however convey empathy and support. The patient may show a variety of emotions, including disbelief, shock, anger, guilt and blame. The patient may cry, so be prepared to give them time to do so, and have tissues available. You may need to give permission to the patient to express their emotions. Use phrases such as: “How does the news leave you feeling?” or “I’m sorry – the news can’t be easy for you”. Listen to the patient’s concerns and address them to the best of your abilities. Allow the patient to ‘shut down’ – appear to turn off and stop listening. This may be because the patient is moving into denial or he/she may need time and space to assimilate the information before moving on. Don’t be afraid to allow periods of silence during the interview. One of the most important factors within the interview is not to be afraid to show your own emotions.
House-keeping Roger Neighbour defined a five-stage consultation model of which the fifth and final stage is termed ‘house-keeping’. This is the time for a doctor to review his/her own feelings following a patient contact.5 Breaking bad news to a patient is particularly difficult, so ensure that you have an opportunity to talk to any other team members that were present at the interview. Also talk to colleagues, especially senior colleagues, about the patient’s reactions and the impact of these on you personally.
Conclusion Bad news that is given well can be beneficial in a number of ways. These include: • empowering the patient • improved psychological outcome for the patient • facilitation of open discussion • reduced stress level in doctors. Breaking bad news to a patient is an extremely difficult task and can be very emotionally draining for the doctor. However, it can also be a very rewarding process in terms of building relationships both with the patient and their family, as well as being an important part of a well-functioning team. ◆
Plan One of the important outcomes of the interview is to leave the patient with a plan for what is to happen next. Having addressed specific concerns raised by the patient during the course of the interview, offer assistance by teasing out manageable concerns from overwhelming emotions and feelings. Prioritize issues and help the patient to identify solutions for the fixable having distinguished these from the unfixable concerns. This is a good opportunity to offer clear support to the patient by using phrases such as: “We can work on this together…” or “Between us, we can….” This may be particularly useful when discussing opening up the information for family members and friends. The planning phase offers an ideal opportunity to emphasize the importance of quality of life. Providing the patient with a clear plan will help to reduce their anxieties and worries. As closure to the interview, summarize and check understanding with the patient. Offer further times to discuss questions and concerns that are sure to arise as the patient spends time reflecting on the interview.
THE FOUNDATION YEARS 4:4
References 1 Buckman R. Breaking Bad News: a guide for health care professionals. Baltimore: John Hopkins University Press, 1992. 2 Faulkner A. When the news is bad: a guide for health care professionals. Cheltenham: Stanley Thorpe Ltd, 1998. 3 Faulkner A, Maguire P. Talking to cancer patients and their relatives. Oxford, 1994. 4 Russell GC. The role of denial in clinical practice. J Adv Nurs 1993; 18: 938–40. 5 Neighbour RH. The inner consultation. Lancaster: MTP Press, 1987.
163
© 2008 Elsevier Ltd. All rights reserved.
Breaking bad news
Relevance to the curriculum
Sarah L Greening
4.0 Relationship with patients and communication skills (ii) Breaking bad news
nature, the patient’s emotions and reactions are very likely to be completely different to your own. Setting • Organize privacy – preferably in a separate room. • Ensure chairs are available so that everyone present can sit down. • Ensure that the time is protected – if necessary, ask a colleague to hold your bleep so that there are no interruptions.
Breaking bad news to a patient may be viewed as one of the most difficult areas within the job of a doctor. Bad news may be defined in a variety of ways, including ‘any information which adversely and seriously affects a patient’s view of his or her future’.1 Examples of bad news include: • telling a patient that they have cancer • telling a patient that they are HIV positive • telling a couple that they cannot have children • telling a spouse that their husband/wife has Alzheimer’s. The result of any bad news is that the patient’s perspective on their future will alter irrevocably, potentially resulting in a very different future and lifestyle. It is acknowledged within many studies that the way in which the news is given by the doctor has a major impact on the patient, so it is important that the information is conveyed in the most appropriate manner. Bad news should be given directly to the patient, unless the patient has expressly instructed that the information is given to a family member, or the patient has impaired understanding due to a psychiatric disorder, confusion or altered levels of consciousness. Sensitivity, dignity and respect are paramount and the information must be shared in a way that is acceptable and understood, with minimum risk of future problems such as collusion.2
Patient • Check whether the patient requires a family member or close friend to be present at the interview. • If English is not the patient’s first language, ensure that the appropriate translation service is available. • If the patient has problems with hearing, ensure that facilities are available to reduce the impact of this, for example, the hearing aid is in the patient’s ear!
The interview It is important to start by checking with the patient what their current perceptions are, and to discover what has happened since you last saw them. This will provide you with the opportunity to judge how the patient is feeling and allow you to gauge how much the patient wants to know.3 This is extremely important, as there are patients who choose to remain ignorant of bad news as this is key to their coping mechanisms. A patient’s refusal of offered information is a form of personal care that protects the individual from threat to self.4 Bear in mind that it is not necessarily permanent, and the offer of information will need to be repeated in the future to provide the opportunity for a change of mind. On the other hand, you may be surprised by the detail that the patient is already aware of.
Preparation Preparation for the interview with the patient can be seen in three parts. Yourself • Familiarize yourself with the patient’s records, so that you are aware of the history and investigations up to this point. During this familiarization, consider questions that the patient may ask that link to the progress to date. • Rehearse the discussion either on your own or with a colleague. • Arrange for a colleague such as a member of the nursing team to be present for the interview. • Consider your own feelings and emotions about the case in order to set them to one side as much as possible. Bear in mind that even if you have had personal experience of a similar clinical
Providing information Provide a warning that the news is going to be bad. The use of phrases such as “I’m afraid that it looks more serious than we had hoped….” can be useful at this point. Then provide the basic information in a simple, straightforward and honest way. Avoid the use of jargon and repeat important points. Although you may feel uncomfortable sharing the information, remember to provide small chunks of information at a time and check the patient’s understanding. Avoid the use of terms like “There is nothing more that we can do…” as there will be plenty more that can be offered, for example, in terms of palliative care – symptom control and emotional support. Allow the patient the opportunity to ask questions at various points of the interview. Don’t avoid questions because you may not know the answers. If you do not know the answer, then offer to ask another member of the team. Avoid using specifics in terms of timeframes – it is reasonable to talk in prognostic terms
Sarah L Greening MB ChB MRCGP DRCOG is a General Practitioner and GP Trainer at Langham Place Surgery in Northampton, UK. She qualified from Leicester and completed Vocational Training in Kettering. Her clinical interests include women’s health and palliative medicine. Conflict of interests: none declared.
THE FOUNDATION YEARS 4:4
162
© 2008 Elsevier Ltd. All rights reserved.
Professional skills of weeks or months or years but if you add a figure to the timeframe at this time it may well be incorrect and the patient is likely to recall this figure as one of the key facts of the interview. Time within the interview is extremely important as each patient will react differently to the information that you are providing. Also, be prepared to come back to the patient on another occasion to repeat the information in order to improve clarification. During the interview, it is important to offer to speak to members of the patient’s family, with the patient’s consent, as the patient may perceive this as quite a burden.
It is important to identify support mechanisms for the patients such as friends and family. You may then repeat the offer to speak to others on the patient’s behalf. This is also a good time to make written materials available for the patient (and family) to peruse at their leisure. Documentation It is vital to communicate with the rest of the team after the interview. This includes the patient’s GP if you are working within secondary care, as it is the GP who will have further conversations with the patient following discharge. It also allows others to identify any levels of denial that the patient has. Document key details of the conversation in the patient’s notes and if you are sending a letter, include notes of the conversation in the letter. Consider offering a copy of this letter to the patient as he/she may find it a useful tool particularly when talking to other family members and close friends.
Support During the interview, monitor the patient’s emotions using both verbal and non-verbal clues and cues. Acknowledge their feelings but avoid using the term “I know how you feel”, as even if you have had a similar personal experience your emotions and feelings are likely to be very different to those of the patient. The use of a phrase such as “I can understand how difficult this must be for you” does however convey empathy and support. The patient may show a variety of emotions, including disbelief, shock, anger, guilt and blame. The patient may cry, so be prepared to give them time to do so, and have tissues available. You may need to give permission to the patient to express their emotions. Use phrases such as: “How does the news leave you feeling?” or “I’m sorry – the news can’t be easy for you”. Listen to the patient’s concerns and address them to the best of your abilities. Allow the patient to ‘shut down’ – appear to turn off and stop listening. This may be because the patient is moving into denial or he/she may need time and space to assimilate the information before moving on. Don’t be afraid to allow periods of silence during the interview. One of the most important factors within the interview is not to be afraid to show your own emotions.
House-keeping Roger Neighbour defined a five-stage consultation model of which the fifth and final stage is termed ‘house-keeping’. This is the time for a doctor to review his/her own feelings following a patient contact.5 Breaking bad news to a patient is particularly difficult, so ensure that you have an opportunity to talk to any other team members that were present at the interview. Also talk to colleagues, especially senior colleagues, about the patient’s reactions and the impact of these on you personally.
Conclusion Bad news that is given well can be beneficial in a number of ways. These include: • empowering the patient • improved psychological outcome for the patient • facilitation of open discussion • reduced stress level in doctors. Breaking bad news to a patient is an extremely difficult task and can be very emotionally draining for the doctor. However, it can also be a very rewarding process in terms of building relationships both with the patient and their family, as well as being an important part of a well-functioning team. ◆
Plan One of the important outcomes of the interview is to leave the patient with a plan for what is to happen next. Having addressed specific concerns raised by the patient during the course of the interview, offer assistance by teasing out manageable concerns from overwhelming emotions and feelings. Prioritize issues and help the patient to identify solutions for the fixable having distinguished these from the unfixable concerns. This is a good opportunity to offer clear support to the patient by using phrases such as: “We can work on this together…” or “Between us, we can….” This may be particularly useful when discussing opening up the information for family members and friends. The planning phase offers an ideal opportunity to emphasize the importance of quality of life. Providing the patient with a clear plan will help to reduce their anxieties and worries. As closure to the interview, summarize and check understanding with the patient. Offer further times to discuss questions and concerns that are sure to arise as the patient spends time reflecting on the interview.
THE FOUNDATION YEARS 4:4
References 1 Buckman R. Breaking Bad News: a guide for health care professionals. Baltimore: John Hopkins University Press, 1992. 2 Faulkner A. When the news is bad: a guide for health care professionals. Cheltenham: Stanley Thorpe Ltd, 1998. 3 Faulkner A, Maguire P. Talking to cancer patients and their relatives. Oxford, 1994. 4 Russell GC. The role of denial in clinical practice. J Adv Nurs 1993; 18: 938–40. 5 Neighbour RH. The inner consultation. Lancaster: MTP Press, 1987.
163
© 2008 Elsevier Ltd. All rights reserved.