Breaking Bad News
Objectives:
Students will:
• Recognize essential principles of
breaking bad news.
• Identify pitfalls in delivering breaking
bad news.
• Apply skills of breaking bad news in a
simulated situation.
THE BAD NEWS ABOUT BREAKING BAD
NEWS IS THAT BAD NEWS IS
BAD NEWS
DEFINITION OF BAD NEWS
Bad News
any news that drastically and negatively
alters the patient’s view of their future
Buckman R. BMJ1984
Bad News
any news that drastically and negatively
alters the patient’s view of their future
Buckman R. BMJ 1984
Bad News
any news that drastically and negatively
alters the patient’s view of their future
Buckman R. BMJ 1984
It alters one’s self-image : “I left my
house as one person & came home
another.”
Professional cyclist Lance Armstrong’s recollection
Examples of Conditions
Requiring Breaking of Bad
News ???!!!!
Examples of Conditions Requiring
Breaking of Bad News
• Cancer related diagnoses
• Intra uterine foetal demise
• Life long illness: Diabetes, Epilepsy
• Poor prognosis related to chronic
diseases: loss of independence
Examples of Conditions Requiring
Breaking of Bad News(cont)
• Informing parents about their child’s
serious mental/physical handicap
• Giving diagnosis of serious sexually
transmitted disease …catastrophic
psychosocial results
• Non clinical situations like giving
feedback to poorly performing trainees
or colleagues
The Good News! about Bad News!!!
• Using a plan for determining the
patient’s values, their wishes for
participation in decision making, and a
strategy for addressing their distress
when the bad news is disclosed can
increase our confidence in the task.
The Good News! about Bad News!!!(cont)
• It may also encourage patients to
participate in difficult treatment
decisions
• Those who do so have a better quality
of life
• Clinicians who are comfortable with
giving bad news are subject to less stress
and burnout.
‫عن أبي يحي صهيب بن سنان رضي هللا عنه قال‪:‬‬
‫قال رسول هللا صلى هللا عليه وسلم‪:‬‬
‫(( عجبا ألمر المؤمن إن أمره كله له خير وليس‬
‫ذلك إال للمؤمن‪ :‬إن أصابته سراء شكر فكان خيرا‬
‫له‪ ،‬وإن أصابته ضراء صبر فكان خيرا له)) رواه‬
‫مسلم‬
Do You Tell??
Do You Tell?
Recent studies have shown that:
• Patients generally (50-90%) desire full & frank
disclosure, though a sizeable minority still may not
want the full disclosure. (Ley p. Giving information to
patients. New York: Wiley, 1982 )
So the issue is not “do you?”
Issue is “how?”
Do You Tell?
In reality, patients who are dying,
know they are dying
 They want confirmation of their status
 They want a time frame
YOU would want a time frame when
your time approaches
Is this Difficult to break the bad news?
WHY?
Is this Difficult to break the bad
news?
• It is referred by some physicians like
“dropping the bomb”
Baile W F, oncologist 2000
Why is this Difficult?
Social factors
Our society values youth, health, wealth
Elderly, sick and poor are marginalized
Sick and dying have less social value
Why is this Difficult?
Physician factors
Fear of causing pain
Uncomfortable in uncomfortable
situations
Sympathetic pain due to patient’s
distress
Why is this Difficult?
Fear of being blamed
Physicians have authority, control,
privilege and status
 When medical care fails patient it’s
physician’s fault
“blame the messenger”
Why is this Difficult?
Fear of therapeutic failure
 Medical system reinforces idea that poor
outcome and death are failures of ‘system’
and by extension, our failure
“all disease is fixable”
“better living through chemistry”
We are trained to feel this way; “if only……”
Why is this Difficult?
Fear of medico-legal system
Everyone has “right” to be cured;
If no cure happens, someone is to blame
Why is this Difficult?
Fear of not knowing
“we don’t do what we don’t do well”
Good communication is a skill that is not
highly valued, therefore not taught
Why is this Difficult?
Fear of eliciting reaction
“don’t do anything unless you know
what to do if it goes wrong”
Not trained to handle reactions
Not trained to allow emotion to come
out
Why is this Difficult?
Fear of saying “I don’t know”
We are never rewarded for lack of
knowledge
Can’t know or control everything
Why is this Difficult?
Fear of expressing emotions
Viewed as unprofessional
Suppressing emotions increases distance
between ourselves and patients
Rabow & Mcphee (West J. Med 1999) described:
“Clinicians focus often on relieving patients’ bodily pain,
less often on their emotional distress & seldom on
their suffering.”
Why is this Difficult?
Ambiguity of “I’m sorry”
Two meanings
“I’m sorry for you”
“I’m sorry I did this”
Easily misinterpreted
Why is this Difficult?
Fear of one’s own illness and death
Cannot be honest with the dying unless
you accept you will die
So How Do We Do This??
Never, never, never, ever…
NEVER “assume”
If you need to know something
If you want to know something
If you need to know something
If you want to know something
ASK!!
THINGS GO WRONG WHEN:
* WE TRY TO ESCAPE
* WE REACT IN ANGER
* WE DILUTE THE AGENDA
THINGS GO WRONG WHEN:
WE TRY TO ESCAPE:
•
•
•
•
•
•
INAPPROPRIATE DELEGATION
DISTRACTION
FRONTAL ATTACK
INTELLECTUALIZATION
MINIMIZATION
EMPTY REASSURANCE
THINGS GO WRONG WHEN:
WE REACT IN ANGER:
•
•
•
•
•
TO DENIAL
TO IDEALIZATION
TO REHEARSAL OF THE STORY
TO ‘UNREASONABLE’ DEMANDS
TO ANGER AND BLAME
THINGS GO WRONG WHEN:
WHEN WE DILUTE THE AGENDA:
• BILLING
• PRACTICAL ARRANGEMENTS
• REQUEST FOR POST MORTEM
The SPIKES Protocol
• SETTING UP the interview
• Assessing patient’s PERCEPTION
• Obtaining the patient’s INVITATION
• Giving KNOWLEDGE and information
• Addressing the patient’s EMOTIONS
• STRATEGY and SUMMARY
SPIKES
Step 1: S - SETTING UP the interview
• Preparation Preparation- Preparation
• Always in person, face to face
NEVER on telephone
• Plan, arrange for privacy, involve significant
others
• Sitting down, Non Verbal Behaviour
• Manage time constraints and interruptions
SPIKES
• Step 2: P –
Assessing The PATIENT’S PERCEPTION
• Gather before you Give
• Patient’s knowledge, expectations and hopes
• What do they understand about the situation?
Unrealistic expectations?
• What is their state of mind? Hopes?
• Opportunity to correct misinformation and tailor
your information
SPIKES
• Step 3: I – Obtaining the patient’s
INVITATION
• Gather before you give
• How much does the patient want to know?
Coping strategy?
• Answer questions, offer to speak to another
SPIKES
• Step 4: K – Giving KNOWLEDGE and
information to the patient
•
•
•
•
•
•
•
•
Warning shot
Use simple language, no jargon,
Vocabulary and comprehension of patient
Small chunks, avoid detail unless requested
Pause, allow information to sink in
Wait for response before continuing
Check understanding
Check impact
SPIKES
• Step 5: E – Addressing the patient’s
EMOTIONS with empathic responses
• Shock, isolation, grief
• Silence, disbelief, crying, denial, anger
• Observe patient’s responses and identify
emotions
• Offer empathic responses
Emotions of the patient
• Respond to patients’ emotions with empathy
• Often shock, isolation, disbelief, grief or anger
Observe for emotion on patient’s part
Identify the emotion.
Identify the reason for the emotion
Connect with the patient
Emotions of the patient
• Exploratory questions
How do you mean?
Tell me more about it
You said it frightens you
You said you were concerned about your
children, tell me more
Could you tell me what you are worried
about?
Emotions of the patient
• Validating responses
I can understand how you felt that way
I guess anyone might have the same
reaction
You are perfectly correct to think that way
Your understanding of the reason for the
tests is very good
Many other patients have had a similar
experience
Emotions of the patient
• Doctor: “I’m sorry to say that the X-ray shows
that the chemotherapy is not working [pause].
Unfortunately, the tumor has grown
somewhat”
• Patient: “I’ve been afraid of this!” [Cries]
• Doctor: [Moves his chair closer, offers the
patient a tissue and pauses,] “I know that this
isn’t what you wanted to hear. I wish the
news were better”
What is Empathy?
The capacity to recognise emotions that
are being felt by another person.
Empathic Responses
• An indication to the patient that you recognise
what they are feeling (and why)
• Verbal and Non verbal
• Often associated with the impact of the news
rather than the understanding.
• Wait for response
• Clarify
Emotions of the patient
Empathic statements
I can see how upsetting this is to you
I can tell you were not expecting to hear
this
I know this is not good news for you
I’m sorry to have to tell you this
This is very difficult for me also
I was also hoping for a better result
SPIKES
• Step 6: S – STRATEGY and SUMMARY
• Are they ready?
• Involve the patient in the decision making
• Check understanding
• Clarify patient’s goals
• Summarise
• Contract for future
REVISION OF THE 6 STEPS
Six Step Protocol
-arrange physical context
-find out what patient knows
-find out what patient wants to know
-share information
-respond to patient’s feelings
-plan follow-through
Arrange physical context
Always in person, face to face
NEVER on telephone
Assure privacy
Verify who is present
Verify who should be present
ASK
Arrange physical context
Remove physical barriers
Sit down
patient-physician eyes at same level
appear relaxed, not casual
(avoid ‘open 4’)
Touch patient (appropriately)
above the waist, handshake, shoulder
Find out what patient knows
Not just knows, but understands
Use open questions
closed questions excellent for historytaking
prevent discussion
Find out what patient knows
Listen effectively to response:
tells understanding, ability to
understand
Repeat back what patient says
Do not interrupt
Make encouraging cues
Maintain eye contact
Find out what patient knows
Tolerate silences
Listen for “buried question”
question asked while you are speaking
Find out what patient wants
to know
Ask!!
Do not allow families to run interference
If patient chooses not to know now, may
ask later
Share the information
Plan agenda
know beforehand what information has
to get across
eg diagnosis, treatment, prognosis,
support
Start by aligning with what patient knows
Share the information
Allow patients to ‘get ready’
Impart information in small packets
best case retention = 50%
Speak English, not “Doctor”
Verify message is received
Respond to feelings
Acknowledge emotions
strong emotions prevent communication
identify and acknowledge them
Learn to be comfortable with silence and
with emotion
Respond to feelings
Range of normal reaction is wide
give latitude as much as possible
stay calm, speak softly
be gentle, yet firm
stick to basic rules of interview:
question-listen-hear-respond
Respond to feelings
Distinguish between adaptive and
maladaptive behaviors
Adaptive
anger
crying
bargaining
fulfilling an ambition
fear
hope
Maladaptive
rage
collapse
manipulation
impossible “quest”
anxiety/panic
unrealistic hope
Respond to feelings
Respond with empathic responses
“it must be very hard to…”
“you sound angry (afraid, depressed)…”
Respond to feelings
In the face of true conflict: act, don’t react
If you cannot change behavior, get help
Planning follow-through
Have plan of action
Make certain patient’s understand what is
fixable and what is not
Always be honest
Patient leaves with contract:
what will happen, who to call, how
to call, when to return
You have one chance to get this
conversation right
Patient/family will remember this always
How do you want to be remembered?
How to Break Bad News: A Guide for
Health Care Professionals
Robert Buckman, M.D.
Johns Hopkins University Press, 1992
ISBN: 0-8018-4491-6
• Scenario 1
Tariq, a 55-year-old chain smoker taxi driver with
persistent cough for 3 months, attends your clinic to
find out the biopsy report of a lesion shown on a
chest x-ray and CT scan. He is rather anxious, that he
has a serious condition.
His biopsy report confirms that he has a Bronchogenic
Carcinoma of right lung.
You are required to proceed with this consultation.
Scenario 2
• A 54-year-old lady attends your clinic to find out the
result of an MRI of her spine. She has had constant
pain all over her spine for the last 2 months. She also
has a history of Breast cancer, which was treated 5
years ago.
• Her report shows that she has secondaries all over her
spine
Proceed with this consultation.
(Examination not required)
SAQs
(1) One of the famous strategy for breaking bad news is
the SPIKES Model:
Explain briefly any 3 of the 6 areas mentioned in this
model?
(2) What is a warning shot? What you say and what
skills you use after and before breaking bad news?
(3) Breaking bad news is difficult: Give 3 reasons for
that?