BREAKING BAD NEWS
Saleh al-zahrany
Rajab al-zahrany
Khalaf al-amery
Mohareb al-reshedy
Abdul-rahman al-serhani
Abdul-rahman al-howiti
Breaking Bad News
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Objectives
Understand why this is an important part of
communication skills.
Understand the definition of bad news.
The students should become aware of:
 What to do?
 How to do it?
 What not to do?
Students should become familiar with certain illnesses/
problems which may require giving bad news.
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Introduction :
By
Saleh alzahrani
‫ قال رسول هللا‬:‫عن أبي يحيى صهيب بن سنان رضي هللا عنه قال‬
:‫صلى هللا عليه وسلم‬
‫ إن‬:‫(( عجبا ألمر المؤمن إن أمره كله له خير وليس ذلك إال للمؤمن‬
‫ وإن أصابته ضراء صبر فكان خيرا‬،‫أصابته سراء شكر فكان خيرا له‬
‫له)) رواه مسلم‬
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The Prophet (Peace be upon him) said :
“How wonderful is the affair of the believer, for
his affairs are all good, and this applies to no one
but the believer. If something good happens to
him, he is thankful for it and that is good for him.
If something bad happens to him, he bears it with
patience and that is good for him.”
Case Scenario
During morning clinic, you receive a phone call
from the radiologist at your local hospital.
A chest x-ray carried out on Mr. khaled shows
features highly suggestive of lung cancer.
You remember that Mr. khaled is a 50 year old in
your practice area.
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From this scenario what is the bad news ?
Bad News definition
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Bad news can mean different
things to different
people. There have been numerous definitions of bad
news including :
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"any information, which adversely and seriously affects
an individuals view of his or her future" Buckman R.
(1992) Breaking Bad News: A Guide for Health Care
Professionals.
Or
 “any news that drastically and negatively alters the patients
view towards future.” Buckman R. BMJ1984
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Examples :
A patient who is told they are HIV positive.
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The man who is told his partner has Alzheimer's
disease.
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The patient who is told the lump has been
diagnosed as cancer.
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The couple who are told they cannot have
children.
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Life long illness: Diabetes , epilepsy
Why braking bad news is an important
part of communication skills ?
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It is a difficult but fundamentally important task for
all health care professionals, yet little formal
education & training is offered for this daunting
task.
Simple Video :
http://www.youtube.com/watch?v=Q5Q-isP-JqY
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References :
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Prof : Riaz Qureshi presentation .
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DR:YOUSEF AL TURKI presentation.
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Department of Health, Social Services and Public Safety ,
Castle Buildings, Belfast BT4 3SJ
Buckman R. (1992) Breaking Bad News: A Guide for Health
Care Professionals.
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Buckman R. BMJ1984
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You tube
Psychosocial Context
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Patients response is influenced by previous
experiences & current social circumstances--inappropriate timing
Even simple diagnosis being incompatible with one’s
profession---tremors in cardiac surgeon.
Varying needs of patient & family---patients wishes
to know more himself & less information to pass on
to family, family wishes vice versa.
Barriers to effective disclosure
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It is referred by some physicians like “dropping the bomb”

Baile W F, oncologist 2000
common Barriers include
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Physicians fears of
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Being blamed by patient
Not knowing all the answers
Inflicting pain & sufferings
Own illness & death
Lack of training
Lack of time
Multiple physician---who should perform the task
Patient’s perspective
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Most important factors for patients include
 Physician’s
competence, honesty & attention
 The time allowed for question
 Straightforward & understandable diagnosis
 The use of clear language
 Parker
PA, Baile WF j.clinical onc 2001
Family's perspective
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Family members prefer
 privacy
 Attitude
of person who gave the bad news
 Clarity of message
 Competency of physicians
 Time for questions
 Jurkovich
GJ, et al. J Trauma 200
Delivering Bad News
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“It is not an isolated skill but a particular form of
communication.”
 Frank
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A. Eur J of Palliat care 1997
Rabow & Mcphee (West J. Med 1999) described:
“Clinician focus often on relieving patients’ bodily
pain, less often on their emotional distress & seldom
on their suffering.”
Delivering Bad News
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Rabow & Mcphee (West J. Med 1999) synthesized
comprehensive model from multiple resources that
uses a simple mnemonic of ABCDE
Advance Preparation
Build a therapeutic environment/relationship
Communicate well
Deal with patient & family reactions
Encourage and validate emotions
Advance Preparation
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Familiarize yourself with the relevant clinical
information (investigations, hospital report)
arrange for adequate time in private, comfortable
environment
Instruct staff not to interrupt
Be prepared to provide at least basic information
about prognosis and treatment options (so do read
it up)
Advance Preparation
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Mentally rehearse how you will deliver the news.
You may wish to practice out loud, as you would
prepare for public speaking. Script specific words &
phrases to use or avoid.
Be prepared emotionally
Build a therapeutic
environment/relationship
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Introduce yourself to everyone present and ask for
names & relationships to the patient
Summarise where things have got to date, check with
patient
Discover what has happened since last seen
Judge how the patient is feeling/thinking
Determine the patient’s preferences for what and how
much they want to know
Build a therapeutic
environment/relationship
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Warning shot “I’m afraid it looks more serious than
we had hoped”
Use touch where appropriate
Pay attention to verbal & non verbal cues
Avoid inappropriate humour or flippant comments
Assure patient you will be available
Communicate well
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Speak frankly but compassionately
Avoid euphemisms & medical jargon
Allow silence & tears; proceed at patient’s pace
Have the patient describe his/her understanding of
the information given
Encourage questions & allow time
Write things down & provide written information
Conclude each visit with a summary & follow up plan
Deal with patient and family reactions
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Assess & respond to emotional reactions
Be aware of cognitive coping (denial, blame, guilt,
disbelief, acceptance, intellectualization)
Allow for “shut down”, when patient turns off & stops
listening
Be empathetic; it is appropriate to say “I’m sorry or I
don’t know. Crying may be appropriate
Don’t argue or criticize colleagues
Encourage and validate emotions
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Offer realistic hope and encouragement about
options available
Give adequate information to facilitate decision
making
Explore what the news means to the patient &
inquire about spiritual needs
Inquire about the support systems they have in
place
Encourage and validate emotions
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Attend to your own needs during and following the
delivery of bad news (counter-transference:
triggering poorly understood but powerful feelings)
Use multidisciplinary services to enhance patient care
( hospice)
Formal or informal debriefing session with concerned
team members may be appropriate to review patient
management & their feelings
WHAT TO DO?
WHAT NOT TO DO?
HOW TO DO IT?
By
Abdul-Rahman Awad Al-Serhani
Case Scenario
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A 73 year old male patient has been admitted via
ER with increasing shortness of breath. A chest X-ray
confirms a large right sided pleural effusion. A
diagnostic and therapeutic tap is performed. The
cytology confirms cancerous cells, primary unknown.
What and How to do?
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Preparation
Know the personal details of the patient.
Have all the information readily available.
Determine what the patient already knows.
Prepare yourself for what you will say.
Have someone else present if necessary - if possible,
someone who has had prior contact with patient, or
a relative/friend. Assess/ask who they would like to
have with them.
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Appropriate time
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Look to comfort and privacy
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Introduction
Introduce yourself properly.
Spend a few minutes establishing rapport.
Ask for information from the recipient to establish their
knowledge of the situation.
Mistake:
Hurry
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Achieving understanding
Speak clearly, other language.
using non-medical terminology.
Repeat.
Regularly check understanding.
Mistake:
Use medical terminology or unclear
language/words.
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Identify the patient’s main concern.
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Warn the patient that bad news is coming.
 Tell
them how very sorry you yourself are
about what has happened:
 "I cannot begin to imagine how you may be
feeling at the moment."
 "May I say how very sorry I am about what
has happened."
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Break the Bad News
Give information in small chunks
Mistakes:
Give all the information in one go
Give too much information
Be blunt. Words can be like loaded pistols/guns
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Pacing and shared control
Try to lead the patient towards making the
diagnosis.
Let the patient take some of the lead - involve them
in the management decisions.
Allow for pauses - silences are useful.
Do not be afraid of silence or tears.
Allow them to ask questions.
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Responding to emotions
Be sensitive
Touch the patient/relative if appropriate.
Reassure them that is alright for them to cry. Allow
expression of emotion.
Maintain eye contact and non-verbal
communication.
Show your own emotion.
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Offer realistic hope (Honesty)
Offer both worst and best scenarios.
If appropriate, leave the recipient of the news with
some hope.
Take responsibility for any mistakes.
Do not be afraid to say things like "sorry" and "I don't
know" - more useful to be honest if you do not have
the full clinical knowledge
Mistakes:
Lie or be economical with the truth
Guess the prognosis (She has got 6 months, may be 7)
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Support
Highlight any positive help eg. pain relief.
Offer continuing support/ practical advice.
Have a plan for the future - help the
patient/relative to plan.
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Summarize and check understanding (Closure)
Summarize at the end of the discussion.
Finish with any positive points.
Close discussion by inviting questions.
Make sure the patient can get home OK.
If the patient can’t, make sure that some one is with
the patient when he leaves.
Set the next meeting and arrange follow up
Give a telephone number
Things not to say
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Do not say: "I know how you feel" or "Are you
happy with that?" You cannot know how they feel.
The words "happy" and death are not compatible.
Do not try to finish off anyone's sentences. Let them
formulate what they want to say, even if this takes
some time.
Don't ask them to fill in any forms at this point —
e.g. on National Insurance, death certificates etc.
Videos
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http://www.youtube.com/watch?v=Q5Q-isP-JqY
http://www.youtube.com/watch?v=Q5Q-isPJqY&feature=related
References
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Prof. Riaz Qurishi presentation.
Medical education 1995,29,430-435.
Update July 1996 .
Breaking bad news – BMJ Jul 2002
Communicating Bad News A guidance Pack
dart centre for journalism and trauma
Youtube .
Angry patient
By
Abdul-Rahman Al-howiti
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Angry patient
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Angry patients and families pose one of the biggest
challenges for a clinician
Our natural tendency is to respond to anger with
more anger, which always makes everything worse.
Angry is usually obvious but sometimes you should
look for angry signs such as changes in body
language, including a tightened jaw, tense posture,
clenched fists, fidgeting, and any other significant
change from earlier behavior.
Angry Patient
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WHAT TO DO?
remain calm and professional
Try to calm down the patient
Understand the reason of being angry
Listen to him carefully
Let him ventilate his anger or any feelings that led to his
anger
Offer to do something or for him to do something
Express empathy for the patient
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Stay curious about the patient's story
Find out the specifics of the story--encourage the
patient to give the details
Angry Patient
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HOW TO DO IT?
Pause and be attentive
Sit at the same level as the patient, not too close and
not too far, with eye contact
Speak calmly without raising your voice
Avoid dismissive or threatening body language
Encourage the person to speak with open ended
questions
Empathize as much as you can with verbal and non
verbal cues
Be aware of your own safety
Angry patient
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WHAT NOT TO DO?
Glare at the person
Confront him or interrupt him
Patronize him or touch him
Put the blame on others/seek to exonerate yourself
Make unreasonable promises
Block his exit
If the person is a patient,s relative,be mindful about
confidentiality
Being defensive