DrTabassum Alvi
Assistant Professor Psychiatry/Behavioural Sciences
Majmaah University
 Use appropriate strategies to breaking bad news
‘Any news that adversely and seriously affects
an individual’s view of his or her own future is
considered as bed news’
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Doctors don’t know how to do it.
They don’t want to be honest.
They protect patient.
They don’t have time
1)
2)
Information given according to needs of
person.
Cultural myth that we want to protect
patient should be avoided.
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Disclosing the diagnosis of cancer.
Discussing cancer recurrence or failure of
treatment.
Disclosing meta static disease.
Discussing the presence of irreversible disease
or serious treatment toxicity.
Disclosing positive results of genetic tests.
Announcing the death.
This model involves giving full information to every
patient as soon as it is known.
Assumptions
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Patient has right to receive full information about self.
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Doctor has obligation to provide information.
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All patients want to know bad news about them.
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Patient should decide what treatment is best for
them.
Advantages
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Promotes doctor-patient trust.
Enhance family support.
Allowing time to put affairs in order.
Helpful for those who cope by finding out
maximum information.
Disadvantage
Discussion of options in detail may frighten and
confuse some patients.
 Insisting on information may undermine defenses.
 Lastly full information may have negative
emotional consequences for some patients.
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This view states that under no circumstance should
patients be informed that they have acquired a lethal
disease.
It is based on the principle that the patient needs
protection from the terrible reality of terminal illness.
Assumptions
It is appropriate for doctor to decide what is best
for the patient.
 Patients do not want to hear bad news about
them.
 The patients need to be protected from bad news.
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Advantages
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It is easier
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Less time consuming
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Suits those people who prefer not to know their
condition.
Disadvantage
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Denial of opportunity to adjust.
Trust in doctor is undermined.
Opportunity for helpful intervention are lost.
Patient compliance is less likely.
Disadvantage
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Patients may acquire wrong information that can
lead to avoidance, isolation and a perception of
rejection.
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There are chances that patient loses sense of
control.
In this model the amount of information disclosed and
the rate of its disclosure are tailored to the desires of the
individual patient by doctor-patient negotiation.
Assumptions
 It has the capacity to maximize quality of life for
the patient.
 People are different; it takes time to absorb and
adjust to bad news.
 Partnership relationship is basis for decision
making in patient's best interest.
Advantages
 Needs of the individual is addressed.
 Supportive and trusting relationship with the
doctor is established
Disadvantages
 It is a time consuming process.
 It drains caregivers' emotional resources.
This model implies that information about the patient’s
disease is the right of the doctor and he delivers the
information in a ‘sugar coating’ to minimize the pain and
distress of the patient.
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It is not a recommended method any more.
This model is a modification of model 3. It is a comprehensive
addressing of all the aspects of informational care, and
principles of effective communication and counseling
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To decrease uncertainty
To complete left over work
Needs management
Prepare for grief
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Advance direction
Enhance mutual support by family
Accidental finding will damage doctor- patient
relationship
Other sources can mislead him
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Be honest
Be warm
Be aware of religious & cultural values
Use basic counseling skills
Serve as a series of continuous support &
encouragement as long as possible
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Encourage questions & legitimate hope that a full
valuable life can still be lived.
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Prepared to receive patients anger.
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Prepared to have professional competence
challenged.
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Prepared not to have all answers.
Senior doctor, fully trained in art of communication.
As soon as diagnosis is certain
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Introduce yourself
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Introduction of subject
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Straight forward way
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Feel concerned with patient
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Use familiar language & simple words
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Indicate facts
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Give time for questions
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Following disclosure patient should be given
private place & time to be with relatives.
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Give few minutes alone to patient to express his
feelings freely
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Soften bad news with good new
 Patient are appreciative of any information that
provides hope (no falsified hope)
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Avoid technical jargon
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Don’t try to give precise prognosis
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Make sure of next appointment arrangement within
24-48 hours
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Continue dialogue
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Instill hope i.e. full & valuable remaining life is
possible
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Encourage patient to talk about meaning of illness
and life
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If patient has fail to ask greater details involve him in
decision making.
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Mobilize coping mechanism
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Frequent short interviews
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Provide information to make intelligent decision
about own treatment.
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Ask patient to write down questions
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Do make an offer to introduce the patient to another
patient with similar condition
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Provide leaflets or written information
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Explanation should be clear & not only technical
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Exclusivity
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Involvement of significant others
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Seating arrangements
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Appear attentive and calm
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Listening mode
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Availability
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The principle involved in this step is “before you tell,
ask". What does he or she thinks about his medical
condition.
Example
1) What did you think was going on with you when you
felt lump?
2) What have doctors told you about all this so far?
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Note the language and vocabulary of the patient.
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If the patient is in denial, try not to confront him in the
first interview.
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Most patients want to know all about their illness but
assumption towards that should be avoided.
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Obtaining overt permission respects the patient’s
right to know or not to know.
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Would you like me to give you details about what
is going on ?
or
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Would you prefer I tell you about the treatment I
am prescribing to you?
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Before you break bad news, give your patient a
warning to prepare him.
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Use same language as it maintain a therapeutic
relationship with the patient.
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Avoid scientific and technical language.
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Give information in small bits and clarify whether he
understands
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Emotions and reactions arise during the interview,
acknowledge them and respond to them.
It comprise of 3 components.
1) One needs to listen and identify the emotion and
acknowledge them.
2) Identify the source of that particular emotion.
3) Respond by showing that you understand the
emotional expression of the patient.
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Recapitulate the information of all that has
been discussed and give your patient an
opportunity to voice any major concerns or
questions.
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Clear plan for the next steps that need to be
taken regarding management of the issues.