Breaking Bad News
Laura G. Ferguson, MD
Texas Palliative Care
The Hospice of East Texas
Communication:
An expert in breaking bad news is not
someone who gets it right every time – he or
she is merely someone who gets it wrong
less often, and who is less flustered when
things do not go smoothly.
- R Buckman
Objectives:
1.
2.
3.
4.
5.
To identify why communication is important
To identify obstacles of communication
To outline general objectives and techniques
of communication in healthcare
To address the uniqueness of breaking bad
news, while reviewing techniques and
approaches to breaking bad news
To review good vs bad communication and
examples of each
Communication

Objectives of communication in
healthcare:
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To explain medical conditions and provide
essential medical information.
To uncover patient and/or family needs,
often by engaging in therapeutic dialogue.
To discuss goals of care.
Communication

Patients look to us for knowledge,
guidance, reassurance, hope,
meaning, and compassion.

Patients know we have been through
similar situations with other patients
and look to us for guidance and what
is “normal”.
Communication
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Unfortunately, the quality of communication
in healthcare is often suboptimal.
Studies show:
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That discussions of bad news do not meet
patient needs and fall short of expert
recommendations.(2-4)
Patients with cancer tend to disclose fewer than
50% of their concerns(5,6) because of inability to
communicate with their physician.
Communication

Studies Show:

The number and severity of unresolved
concerns has been shown to predict high
emotional distress and future anxiety and
depression for patients. (7,8)

Physician predictions of their patient’s wishes
regarding end of life care and life sustaining
treatments were closer to their own choices than
based on the patient’s expressed wishes. (9)
Communication

Studies Show:

In one study of 598 oncologists, 56%
were burned out and 53% attributed this
to the continuous exposure to fatal
illness. (10)
Communication is therapeutic!
Communication
“ No news is not good news, it is an
invitation to fear.”
- CM Fletcher
Obstacles to good communication
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Medical education doesn’t teach
communication.
Communication involves the
psychoemotional and spiritual aspects of
care, with training focusing on cognitive
teaching.
Students are not encouraged to show
emotion or feelings.
Students lack experience with proper
communication and have poor role models.
Obstacles to good communication (13,14)
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Unrealistic expectations of the
healthcare system by society.
Cultural differences in disclosure of
information.
Time limitations of medical staff and
patients.
Lack of trust in the medical system.
Lack of experience with death.
Obstacles to good communication (13,14)

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Terminal conditions and dying are difficult
subjects to talk about for us and for our
patients.
Emotions, such as fear:
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Of the process of dying (symptoms, $ concerns,
loss of independence/control, etc).
Of blame.
Of not having the answers.
Of not knowing how to handle emotional
outbursts.
Obstacles to good communication

Other emotions that these
conversations can elicit:
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Stress
Sadness
Guilt
Loss
Failure
Helplessness
Basic Communication Skills

Setting

Schedule a meeting time.
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This ensures we allocate time, says to the patient “big
news” is coming, and allows family to be present.
Have face-to-face communication.
>50% of communication is nonverbal.
Sit at eye level and within reach of the patient.
Minimize distractions.

Pager and phone off or on vibrate, door closed, ask
colleagues not to disturb you, etc.
Basic Communication Skills

Information exchange

Outline an agenda

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Why are we meeting and what should be
accomplished by the meeting.
Ask open ended questions

See what they understand. This helps to
define a starting point for the conversation.

“What do you understand about your
condition/diagnosis?” or “What have you been told
about your condition?”
Basic Communication Skills

Information exchange
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Determine how much information or how
many details the patient wants to know.
Recognize that the patient and family may be
different in their desire of information.
“The forest” vs “The trees”
Avoid medical jargon or at least define terms.
***Focus should be on the patients’ concerns!
Basic Communication Skills
LISTEN
Basic Communication Skills

Responding
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Address the patients’ concerns.
Use nonverbal cues to demonstrate
attentiveness.
Demonstrate empathy by acknowledging
the patients’ feelings as acceptable.

Ask about perceived emotions.

“You seem angry?” or “I feel you are scared. Do
you want to tell me about how you are feeling?”
Basic Communication Skills

Responding
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Encourage and justify their emotions.
Attend to all issues and needs, including:
physical, psychosocial, and spiritual.
Review Objectives
Summarize

Information, discussions, and decisions
Key Communication Techniques
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Ask open-ended questions
Use nonverbal cues (nods, “uh-huh”)
Provide empathic responses
Use repetition
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Paraphrase
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Repeats back to the patient what they said. Used to prove
listening.
Your summary of what the patient said. Used to ensure
understanding.
Confront emotions…yes, even difficult ones (anger)
Summarize
Open Ended Questions
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What do you understand about your
condition?
What concerns you the most about your
illness, your family, your future?
How is treatment going for you/your family?
What has been most difficult about being ill
so far?
What are your hopes, fears, or expectations
in the future?
What matters to you the most?
When are your best times?
Emotion and Communication

Emotion affects processing of
information
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This is an obstacle because most
hospitalized patients are in a “bad” mood,
which affects how they “hear” the news
being given.
If the patient and family are angry or too
upset, you may not make any decisions
on the initial meeting.
Responding to Patient Emotions (11)
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N - Name the emotion.
U - Understand/normalize the emotion.
R - Respect the patient and family for
how they are coping.
S - Support the patient so they don’t
feel alone.
E - Explore the emotion.
Communication
“Hope is based on knowledge, not
ignorance.”
“What remains unspoken is unspeakable.”
- MA Simpson
Breaking Bad News

Preparation and Setting
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The meeting should be in a private place
with adequate time.
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Suggest a supportive person accompany
the patient.
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Have all information and data available.
Breaking Bad News

Content
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Determine what the patient knows and wants to
know.
Get to the point quickly.
Fire “warning shots”.
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“I have bad news.”
State the information simply, clearly, and sensitively.
Provide information in small chunks.
Avoid false reassurance, but don’t be discouraging.
Make truthful, honest statements.
Breaking Bad News
Listen
Breaking Bad News

Responding to Patient Emotions
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Be empathetic.
NURSE expressed emotions.
Explore hope.
Explore faith.
Be willing to talk about dying.
Assure continued support.
Offer other resources of support.
When communicating with a patient in denial, start
as if the patient has had no previous knowledge.
Breaking Bad News

Empathy:
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The ability to put aside ones personal
agenda and share another being’s
emotions, feelings, and perspective.
Listening to a patients’ feelings.
Expressing you are aware and accepting
of a patients’ emotions.
End-of-Life Communication
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Empathetic body language: SOLER
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Face the patient Squarely
Keep Open body position
Lean forward
Eye contact
Maintain a Relaxed and natural posture
Hope ≠ Lying
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We often convey a prognosis with an
optimistic bias….is this best?
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Studies show that the better a doctor knows
the patient, the more likely the doctor is to
overestimate survival. (16)
On average, physicians are wrong > 80% of
the time when estimating prognosis.
The majority of these inaccuracies are
optimistic (~90%).
Hope ≠ Lying
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Focus on hope and what CAN be
done.
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Explore other goals besides cure.
“I know you are hoping for a cure, but what
other things are you hoping for?”
Breaking Bad News

Wrap Up
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Set up a follow-up meeting.
Provide written materials as adjuncts or
addresses to reliable websites.
Offer to talk to relatives/friends.
Suggest the patient writes down
questions.
Keep communication ongoing.
Breaking Bad News

Three of the greatest challenges with endof-life communication.
1.
2.
3.
To remain present when a patients’ suffering
evokes our fears and insecurities.
To resist the need to do something when
listening is more appropriate.
Supporting a patients’ decision when it’s not in
agreement with what we would recommend.
Breaking Bad News

Studies Show:

Patients prefer to have information about
their diagnosis and prognosis, even when
the news is worse than expected.” (12)

A large, heterogeneous sample of 2331
patients with cancer showed that 2027 (87
per cent) wanted all possible information,
be that good or bad news. (15)
Breaking Bad News

The is no evidence supporting that
terminally ill patients who have not
been told the truth of their situation die
happily in blissful ignorance.

Patients witness and experience their
deteriorating body.
Breaking Bad News
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Communication is a 2-way street
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Patients also have to be honest with us
regarding their symptoms, preferences,
and concerns.
Realistic hopes and aspirations can
only be generated from honest
disclosure.
Words Make A Difference
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Hospice vs. Palliative Care
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Eating vs. Feeding vs. Artificial Nutrition

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Understand the difference.
Eating is usually done independently with your
mouth and feeding is often done by others.
Depression vs. Mood

Ask about a patients’ mood/spirits. There is a
negative stigma associated with depression.
Words Make A Difference
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Resuscitation vs. Natural Decline
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Pain vs. Suffering
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“You” want vs. The patients’ wishes
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Withdrawal care vs. Focus on comfort
Words Make a Difference
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Major discrepancies often exist between what
doctors think they said and what the patient actually
heard/understood. (18)

Example:
Doctor: As you know, we recently checked your blood
and x-rays so we could start your third cycle of
chemotherapy. I reviewed your tests today and
there are signs that things are progressing, so we
do not think that you should have anymore
chemotherapy.
Words Make a Difference
Patient: Oh! So what happens now?
Doctor: Well we just want you to come
see us if you develop any further
problems, like trouble breathing.
Patient: Ok. Well thank you very much
doctor.
Words Make a Difference

Immediately after this consultation the
patient is asked what the doctor said.
“Well it’s good news really. The doctor
says things are progressing so I don’t
need anymore chemo and to just come
back if my breathing starts up
again….getting breathless you know.”
Words Make a Difference

What could the doctor have said?
Doctor: As you know, we recently checked your blood
and x-rays so we could start your third cycle of
chemotherapy. I reviewed your tests and the cancer
is not responding to chemotherapy. We will not do
more chemotherapy because it is not helping. We
don’t want to put you at risk of side effects when
you are not getting any benefit. There are no other
curative treatments we can offer you. Your cancer
is incurable.
Words Make a Difference
Patient: Oh! So what happens now?
Doctor: Well, we focus on what we can do for you,
such as controlling your symptoms. Together we’ll
continue to work to keep you feeling and doing as
good as you can for as long as you can.
LISTEN/RESPOND
Doctor: Can you tell me what you understand about
our conversation? Do you have any questions?
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