1
University of Manchester
Breaking Bad News Course
Communication teaching - Year 4 medical students
Tutor notes 2011 - 12
Course written by Drs Heather Anderson & Simon Cocksedge
Revised June 2011 Simon Cocksedge
Index
Section
Points for all weeks
Session 1
Session 2
Session 3
Roles for session 1
Roles for session 2
Roles for session 3
Student handouts
Page & notes
2-5
5
6
7
8 - 15
16-23
24 - 31
32 - 35
SPIKES is on page 32
Changed for 2011-2012 in response to student feedback – there is now longer for the group
work with SPs in weeks 2 and 3 [roles have 35mins not 30mins]
2
Breaking Bad News: year 4 Communication
Aims of the course
This course runs over three half day sessions and is the major
communication teaching for Year 4 medical students. The aims are:
Week 1- life changing events
 To review basic communication skills
 To introduce topic of BBN and SPIKES – focus: life changing events/conditions
Week 2 – life threatening events
 To practise with more challenging situations – focus: life threatening conditions,
patient not expecting such news
Week 3 – handling strong emotions; relatives
 To learn how to deal with strong emotions e.g. anger,
 To learn how to cope with relatives in ‘bad news’ situations
Clinical topics in the course
Some students ask to know the clinical topics covered each week – we send these to
them in advance and ask them to prepare to discuss these topics:
Week 1
 Hypertension
 Multiple sclerosis
 Rheumatoid arthritis
 Diabetes
 Ankle fracture
Week 2
 Myocardial infarction
 Breast carcinoma
 Oesophageal carcinoma
 Uterine carcinoma
 Bowel carcinoma
Week 3
 Rectal carcinoma
 Chronic obstructive airways disease
 Breast carcinoma
 Pancreatic carcinoma
 Myocardial infarction
3
Guidance on running the small group sessions for all weeks
Before the first SP arrives
Distribute sticky labels to be used as name badges - ask each student to write the
name that they would like to be known by during the session! Make sure that the
chairs are in a circle and that you are sitting in the circle so that you give the sense of
being collaborative.
Explain what will happen in the session. That is you will be visited by 3 simulated
patients; there will be three interviews and time to give feedback to the interviewer.
Explain that as this is a safe environment the SPs won’t be emotionally damaged by
the content of the session.
Preparing for the role play with the SP
Either ask for a volunteer to conduct the first interview or allocate people for all three
interviews to save time later in the session.
Give the student conducting the interview the doctor’s role notes - while he/she
familiarises themselves with the role, you read the role out to the group. Check if
there are any questions or points of clarification – the students may need to share their
knowledge of the illness/condition described in the role. Feedback from previous
tutors has been that when students are unclear about the required medical knowledge
that they are unable to practice and develop their communication skills. You may
need to spend 1-2 minutes discussing the condition to ensure the student feels
equipped to explain it to a patient.
To ensure students don’t passively watch, consider allocating tasks for giving
feedback. For example, you could ask pairs of students to focus on aspects of
SPIKES or on different question styles, use of empathy etc. Ensure observers make
precise notes to enable specific & focused feedback.
Always speak to the SP briefly before he/she comes into the room. You may possibly
suggest what you would like the focus of their feedback to be or how you want them
to play the role [particularly in week 3]. Some students will wish to increase the
emotional intensity demonstrated by the SP. Consider negotiating this with your
group.
Pause button/rewind facility
Tell the students that they may use an imaginary ‘pause button’ at any time, and this
is positive as it shows they are really thinking about what they are doing and the effect
of their intervention with a patient. It means they can temporarily come out of the
interview to talk with the group about what to ask next or which areas they may want
to pursue. It is important that you facilitate group discussion, wherever possible,
rather than you making the suggestions
Reinforce that using the pause button [as often as necessary] is a positive thing to do,
showing that students want to think about the issues/questions.
The student can also rewind the interview and try a different question or approach.
The SP will be ready for this possibility.
4
The interview
Check that the interviewer is clear about how he/she is going to start. If the student is
not sure, have a brief group discussion to pool ideas. Possible questions for you to ask
the student at the beginning are: ‘How are you going to start?’; ‘What help do you
need before starting?’; ‘How are you going to explain…?’
The interview should last no more than 6-8 minutes. You can bring it to a close or
pause it if necessary. Keeping to the overall time schedule is crucial.
Please ensure that the students use SPIKES – particularly that they check the patient’s
concerns and perceptions about what may be wrong with them.
You could ask other students to have a go at a section of an interview or even ask
students to try something different.
Rules of feedback
We generally use Pendleton’s Feedback Rules.
 Observers briefly clarify points of fact
 Interviewer reflects on what went well
 Group members state what went well, giving specific examples
 Simulated Patient in role contributes feedback
 Interviewer state what might be done differently
 Group members, then SP in role, state what might be done differently
 SP taken out of role formally, and asked to comment out of role.
 Interviewer notes the learning points
There are other possibilities in terms of how feedback is managed including asking
the interviewer what they would like feedback on.
The group feedback is captured by another member of the group who records this on
the Student Feedback form. Please encourage role playing students to write a
reflection & develop an action plan from this to keep this in their portfolio.
Finishing the session
Go around the group and ask everyone for one learning point that they will take away
from the session.
Emotional Health Warning
Occasionally, a student may become upset during the session. This is generally as a result of
the themes of the session resonating with their own lives. If a student wants/needs to leave the
room, then please let them go but perhaps ask one of their friends to go and act as support.
Also, try to see the student yourself at the end of the session. You could offer support from
either yourself or another member of the tutor team. It would be helpful if you could let the
Lead Tutor or one of the site administrators know the name of the person concerned.
You could also suggest that the student contacts the University Counselling Service: Tel: 275
2864; www.staffnet.manchester.ac.uk/theguide/ or the pastoral support team at your site.
Click on ‘student support and services office’ for details of counselling service.
5
BBN Session 1
Aim: To review basic Communication skills
To introduce topic of BBN and SPIKES – focus life changing events/conditions
Materials for this session: SPIKES handout, pre-evaluation sheet if used
WHEN WHAT
WHO
NB Get students to sit at the front
0.0
Lead
Introduction
and
complete
initial
evaluation
sheet,
if
used
in
Tutor
lecture
theatre
15min
65min
80min
to small
group
90min
180min
Aims of course
Introduce tutors and simulated patients
Outline programme for the session
Mention possibility of student life problems (to raise the
issue that this course deals with difficult issues, which may
touch on current problems in students’ personal lives).
Students may wish to discuss these with tutors during/after
this course or with others e.g. student counselling service –
see pg 4; exceptionally, individual students may need to
limit their role-playing in the groups.
Brainstorm of communication skills learnt so far
Write up on board: E.g. open/closed questions, room
arrangement, body language, eye contact, summarising,
reflecting, pausing
Talk on breaking bad news: to include giving
out/discussing the student handout (SPIKES) and
mentioning the rules of feedback
Role play by tutors with debriefing
Tutor & SP run a brief role play (7 mins max) - NB this is a
diagnosis of hypertension. They stay on the stage while
another tutor facilitates student debrief using the rules of
feedback– on stage participants model the Pendleton
feedback rules and students need to be told to make notes
and be specific with their feedback
Identify tutors/groups/ venues – emphasise that
punctuality is crucial.
Coffee break 15 mins
Group forming
Discussion of format/name badges/order of role-playing
SPs visit groups for 90 mins (3 roles x 30 mins each). N.B.
check role no. and order allocated to your group on the
detailed schedule Student role plays with SP for six mins,
and then is debriefed by the group using the rules of
feedback. Capture group feedback on Student Feedback
form, encourage role-playing students to develop an action
plan/reflection for their portfolios. Must run to time.
Students depart when finished.
Tutor/SP debriefing- venue site specific
Lead
tutor
Lead
tutor
TUTORS
TUTORS
tutors
6
BBN Session 2
Aim: To practise with more challenging situations – focus: life threatening
conditions, patient not expecting such news
WHEN
WHAT
WHO
0.00
Introduction
Lead tutor
lecture
Aims of session
theatre
Outline programme for the session
Talk recap of SPIKES, & skills learnt so far, talk Lead tutor
5min
on reactions, importance of hope (student
LT
handout on hope), more challenging BBN and
role of palliative care team
40min
55min in
small
groups in
rooms
165min
180min
Role play by tutors with debriefing
Front of house role play- wife Mrs. Liz Clarke,
arrives at hospital, husband, Jim, has died
Tutor & SP run a brief role play (7 mins max)
and stay on the stage while a third tutor
facilitates the students to give feedback
structured on SPIKES(See back of Tutor notes)
Identify groups/tutors/venues and
break for coffee – 15min break
Into groups – 5mins re-forming group then
3 role-plays of 35 mins each. Capture group
feedback on Student Feedback form, encourage
role-playing students to develop an action
plan/reflection for their portfolio.
There is a student handout for this session on
‘The importance of hope’ see page 34. Please
refer to this for at least one of the scenarios.
Students should also have the SPIKES handout
from the last session to refer to.
NB check role no. and order allocated to your
group on the detailed schedule
Debriefing in small groups
Discussion on things learnt so far – each group
member to identify one thing.
Please use this time to encourage students to
reflect on what this learning means for them
individually. Invite students to share examples of
their own experience of bad news [seen as a
student or in their own lives], relating it to this
course. Help them to think about the doctor as a
person as well as a professional. How do
doctors manage difficult professional situations
which may overlap in their personal lives? Eg a
doctor whose father has terminal lung cancer
telling someone they have ca bronchus. Reflect
on what coping/support doctors may need.
Students depart - Tutor/SP debriefing
TUTORS
TUTORS
7
BBN Session 3
Aim: To learn how to deal with strong emotions e.g. anger,
To learn how to cope with relatives in bad news situations
Materials for this session: relatives & anger handouts, evaluation sheets
WHEN
WHAT
WHO
0.00
lecture
theatre
5 min
Lecture
theatre
Introduction
Aims of session
Outline programme for the session
Brief recap of SPIKES, & skills learnt so far,
talk on anger and strong emotions
Lead
tutor
40min
55min
small
groups in
rooms
Lead
tutor
Role play by tutors with debriefing.
Patrick/Patricia son/daughter of Maud
Thompson (patient) Tutor & SP run a brief role
play, a third tutor facilitates the interaction –
pauses role play and asks for advice from
students ‘What could you say/do now?’ Debrief
comments at end
Student handouts: Anger and relatives
Identify groups/tutors/venues and break for
coffee – 15mins
Into groups - 5 mins reforming group then 3
TUTORS
roles with SPs @ 35 min. each
Capture group feedback on Student Feedback
form & encourage each student who role-plays
to develop an action plan/reflection for their
portfolio.
NB check role no. and order allocated to your
group on the detailed schedule
It is important to practise concluding an
interview at least once during the three sessions
with your group. It is vital to do this today perhaps do it by re-running the scenario.
165min
180min
Debriefing in groups
TUTORS
Discussion on things learnt so far – each group
member to identify one thing. Continue
discussion from previous week - doctor as
person & professional, and support for doctors.
If possible, pick up the issue about how you
manage anger & confront racism from the talk
and chat this through with the group
Get students to fill in evaluation sheets, collect
and return to your site administrator.
Students depart
Tutor/SP debriefing in start room
8
SP Role
Patient’s Name Paul/Paula
Course
BBN
Winters
Setting
Neurology clinic
Session
Role
Age
Sex
Other Information
1
1
30-55
M/F
Non
spectacle
wearer
preferable
You are a publican.
Past For several months you have felt a bit weak and run down. This all happened
after a viral infection, which made you feel unwell and dizzy with poor vision. Your
optician said you did not need glasses. (If you wear spectacles your prescription is
OK.)
This all quickly settled. Since then you have felt a bit weak. You keep having
accidents and drop things. Your partner has started to call you clumsy.
About 6 weeks ago you were less well again and people in your pub thought you'd
had too much to drink because your walking was poor. Nobody believed you had only
had one drink that day! You were concerned and thought it could be stress but at the
back of your mind is the possibility of a brain tumour. Your GP arranged for you to
see a specialist at the hospital. You were admitted for 6 days and had lots of tests
including blood tests, x-rays and a brain scan.
You were discharged 2 weeks ago. You have come back to the neurology clinic for
the results, but the specialist, who you saw last time is on holiday.
Role player task
What is your name? Work out your family names e.g. wife or any children.
What is the pub called?
You are worried about yourself because you slipped on the ladder to the cellar and
realise that you could have had a serious accident. Your partner does not know this.
What could you be stressed about?
If you had these symptoms how would you feel?.
9
Doctor Role
Patient’s Name Paul/Paula Winters
Setting
Neurology clinic
Course
Session/Role
BBN
1/1
You are a ST1.
Situation. This patient, who you have not met before, comes to the clinic alone.
(Your consultant is on holiday.) His/her partner is running the pub that they have
together. For several months he/she has been unwell. This illness started after a viral
infection and was associated with dizziness and blurred vision.
He/she has felt tired since, has become clumsy - dropping glasses, and his/her legs are
weak. People have thought he/she was drunk when he/she was not. One of the GPs
arranged for him/her to be admitted to hospital for tests. He/she was discharged two
weeks ago.
He/she has come back for the results. You read through the notes and see that the
MRI scan shows that he/she has demyelination indicating multiple sclerosis.
You need to explain the diagnosis, but he/she will then see the nurse specialist to
explain the next steps.
Role player task
What are you going to say?
How are you going to start?
10
SP Role
Patient’s Name Olive/Clive
Dewar
Setting
GP surgery
Course
Session
Role
Age
Sex
Other Information
BBN
1
2
30+
M/F
You have run a bakery & confectionery shop with your marital partner for 15 years. It
is very successful and now, financially, you do not have to struggle at all. You have
four employed staff, but you do most of the baking, still getting up at 5am to start
work in the kitchens.
Past: You made the fancy cakes and chocolates while your partner was ill with flu. So
you had to manage your job and also make the fancy breads that week. Following
this, (4 weeks ago), you have had stiffness of the hands. After the first week they both
became red, puffy and swollen. You could not bake any more. The joints were
swollen and too stiff to move without pain. You attended your GP surgery 3 weeks
ago. He/she gave you ibuprofen 400mg every 8 hours and this has helped. The
redness and swelling has gone, but your hands remain somewhat stiff, especially in
the morning. The GP did blood tests and sent the samples away for analysis and
arranged for X-rays of your hands.
Now you go to the surgery for the results and to get more tablets. Another problem is
indigestion. The doctor said that the tablets may cause indigestion as a side effect.
Role player task.
Build up a social and work picture.
How long do you think you'll be off work? You are supervising at the moment as you
cannot do any manual work.
You think you may have developed an allergy to the yeast and flour.
You must not forget to get more pills and tell him/her about the indigestion.
11
Doctor Role
Patient’s Name Olive/Clive Dewar
Setting
GP surgery
Course
Session/Role
BBN
1/2
You are a GP.
Situation This patient came to your colleague three weeks ago with a one week
history of stiffness of the hands. Then over the weekend they had become red, puffy
and swollen. S/he could not bake in the cake/confectionery shop that s/he runs with
his/her marital partner. The joints were swollen and too stiff to move without pain.
Your colleague suspected rheumatoid arthritis and did blood tests for this and
arranged for X-rays of the hands. He/she also prescribed ibuprofen 400mg every 8
hours.
Role player task.
You have not met this patient before (your colleague is off sick).
The tests confirm rheumatoid arthritis.
How are you going to tell him/her? The diagnosis will have possible implications
regarding his/her job.
You plan to refer to a specialist if s/he is not back to normal.
12
SP Role
Patient’s Name Arthur Morris
Setting
patient in bed on
orthopaedic ward
Session
BBN
1
Role
Age
Sex
3
25-50
M
Course
You are a mature student – make up a course you are on. You work part-time (as a
store man in a warehouse) to keep some income coming in while studying.
Yesterday, whilst doing your temporary job, you were putting some products on a
high shelf. The ladder you were using slipped and you fell directly onto your feet
about 14 feet below. You were in agony and were rushed to hospital. At casualty Xrays showed a compound fracture of the ankle and calcaneum.
You have been put into a plaster of paris splint and have had pethidine. You are
feeling a bit better now.
You are due to go to Cyprus in two weeks time- make up a reason - could be for a
sports tournament, student exchange, visit relative.
You are a keen sports enthusiast and play in a competitive team. Sport is a big part of
your social life.
Role player task
Build up a social picture - names parents, siblings, partner, hobbies.
What sport(s) and what position do you play?
Think about how you would feel having a fractured ankle - how will it affect you now
and later?
What about your trip to Cyprus?
What do you need to know?
13
Doctor Role
Patient’s Name Arthur Morris
Setting
patient in bed on
orthopaedic ward
Course
Session/Role
BBN
1/3
You are one of the orthopaedic F2 doctors.
Situation Your colleague (who is not here today) saw Arthur Morris yesterday
evening. He is a mature student who has had a fall doing a temporary job (to help pay
his way as a student).
He has a compound fracture of the ankle and calcaneum. This is a fracture in which
broken bone fragments lacerate soft tissue and protrude through an open wound in the
skin. This is a bad fracture and may well heal poorly.
At the X-ray meeting this morning, the prognosis was felt to be poor, and your
consultant recommended surgery.
This will involve plating. Long term, the foot will be stiff and sports etc. will be
difficult. He will probably walk with a limp and competitive sport is likely to be out.
He will need intensive physio for several months after the dressings are removed.
Role player task
You have not met this patient before.
You need to explain the position.
How do you start?
14
SP Role
Patient’s Name Lesley/Leslie Hall
Setting
GP surgery
Course
BBN
Session
Role
Age
Sex
Other Information
1
4
20 - 40
M/F
You are a mature student. You live at home with your parents.
Past You have had some symptoms of cystitis for about three weeks in all. You
initially phoned the GP and a course of antibiotics was prescribed after your telephone
call. You were asked to report back one week later if you were no better.
You were feeling a bit better but still had some urinary symptoms. The fishy smell in
your urine had gone, but you still had to pass urine frequently, including at night. You
attended your GP’s practice nurse who did a stick test of your urine and took blood
for tests.
Now You go back (two days later) for the results, from the GP.
You have been drinking lots to try and flush the kidneys out.
It has been hard to concentrate because you feel tired and intermittently feverish.
Role player task.
Build up a social picture - names of parents, siblings, partner, hobbies.
Think how you would feel about tiredness and your studies.
How has the urinary frequency affected you?
You really think that you are run down with exams coming up and it is just a bad
attack of cystitis. A thought you dismissed was a sexually transmitted disease but you
haven't had sex recently and don't really believe this is a problem.
15
Doctor Role
Patient’s Name
Lesley /
Leslie Hall
Course
BBN
Setting
GP surgery
Session/Role
1/4
You are a GP registrar
Situation Leslie / Lesley is a mature student who has been registered with the practice
all his/her life and lives locally with his/her parents. You have not met him/her before.
He/she had symptoms of cystitis three weeks ago. After a telephone consultation, you
initially prescribed a course of antibiotics, and asked the patient to report back one
week later if they were no better.
He/she presented with persisting frequency to the practice nurse 2 days ago. Dipstick
urine showed increased glucose, so MSU, FBC, B/S and U&E were performed and
he/she was asked to see you today for the results. .
The blood sugar is 36mmol/l; U&E, FBC & MSU normal.
He/she appears to have diabetes mellitus and you need to refer him/her urgently to the
hospital to the Diabetes Centre.
Role player task
How will you explain the diagnosis of diabetes?
How will you start the conversation?
16
SP Role
Patient’s Name Sarah Page
Setting
One stop Breast
Clinic
Course
Session
Role
Age
Sex
Other Information
BBN
2
1
30 -75
F
You are attending the one stop breast clinic. The doctor has taken brief details and
examined you. You have had a mammogram and breast biopsy, all this morning.
Past You were having a bath three weeks ago when you noticed that you had a lump
in your breast. It is not painful and is about an inch in size. It feels hard.
You are aware that this could be something serious e.g. a tumour. You attended the
GP surgery and he/she arranged an appointment at the one stop hospital clinic where
you are now.
You have been told the results will be given to you today. You didn’t know that’s
what happened nowadays – all so fast.
Now: Role player task.
Build up a picture of your family, job, children’s names etc.
You are quite tuned into health problems. You know most breast lumps are not
cancers and part of you wants to know if this one is. You suspect it may be because
the "Readers Digest" article about cancer and all the TV programmes say that painless
lumps often are cancers. You are also aware that treatment is usually surgery and
these days it may not be necessary to have the whole breast removed.
On reflection, you are not sure you want the results today (you came alone) and this is
all happening too fast. If asked, please say you would prefer your husband with you
but you decide [after some discussion with the doctor/student] that you will hear the
news today.
17
Doctor Role
Patient’s Name Sarah Page
Setting
One stop Breast
Clinic
Course
BBN
Session/Role
2/1
You are the one of the breast clinic registrars.
Situation Sarah Page found a painless breast lump three weeks ago. Her GP has
referred her to the hospital. She was seen and examined by your colleague (who has
had to leave) earlier this morning. Following that, she has had a mammogram,
ultrasound and breast fine needle aspiration (FNA) and core biopsy.
The results of her tests are now ready.
The lump is hard and about 2cms big. Clinically cancer is suspected, and this has been
confirmed by the mammogram and FNA. The FNA report reads
MICROSCOPIC DESCRIPTION:
Malignant cells present.
-C5 malignant.
She will see the consultant shortly to discuss the next step. It is likely to be
lumpectomy and axillary surgery followed by radiotherapy. Other treatment (e.g.
chemotherapy, hormone therapy) will be decided at the MDT post surgery.
You need to inform her of the diagnosis and have an initial discussion.
Role player task
Do you want anyone else there?
Decide on the names of colleagues who will be involved in her care (radiologist,
surgeon)
How will you start the conversation?
(fine needle aspiration gives a diagnosis in 1-2hours)
18
SP Role
Patients Name
Setting
Ian/Jan Walker
Hospital outpatient clinic
Course
Session
Role
Age
Sex
Other Information
BBN
2
2
35 -49
M/F
You are a 42-year-old social worker living with Rose/Ron.
Past You have a six week history of indigestion and more recently, some loss of
appetite, heartburn and soreness on swallowing.
You have begun to lose a few pounds in weight. You went to your GP a week after it
started as you had never had indigestion before. The GP prescribed ranitidine
(stomach tablet twice a day).
A week later you were worse so returned to your GP and he arranged a specialist
appointment for investigations. The appointment came through very fast. The
specialist arranged a gastroscopy and tests for a special germ associated with stomach
ulcers, which you had done last week.
Your mother had a hiatus hernia. At worst you think it is a stomach ulcer and that you
will need tablets. You would be apprehensive about surgery but you understand that
surgery is an old-fashioned treatment for stomach ulcers.
Now You had your tests last week and have come back for your results.
Role player task
Build up a social picture. You have no children. What are your hobbies?
You last worked yesterday. Your partner is a ward clerk at the local hospital.
You are looking forward to your holiday in the USA in three weeks.
You have never been ill in your life
How would you feel with these symptoms? How do you feel coming for the results?
What would you be worried about?
19
Doctor Role
Patients Name
Setting
Ian/Jan Walker
Out-patient clinic
Course
Session/role
BBN
2/2
You are the medical F2 doctor
Situation Ian/Jan is a social worker with a six week history of dyspepsia and
anorexia. He/she has lost a few pounds in weight but continues to work. He/she has
some soreness on swallowing.
He/she had a gastroscopy last week and tested negative for H Pylori. There was
evidence of oesophageal reflux and an area of redness and ulceration in the lower
oesophagus was biopsied.
The biopsy report says he/she has adenocarcinoma of the oesophagus.
Role player task
This person is very young ( late 30s early 40s) to have oesophageal cancer and you
are shocked when you see this report on their notes. You need to explain the diagnosis
to him/her.
You may wish to discuss the immediate plans:
He/she needs a pre-operative staging CT scan. This can be done tomorrow.
Your plan is to offer an assessment laparoscopy in the next few days.
He will need follow-on specialist advice (?chemotherapy etc.)
How are you going to explain this unexpected news?
NB carcinoma of oesophagus is serious [very poor 5 year survival rate]
20
SP Role
Patient’s Name Janice Hand
Setting
Hysteroscopy
Clinic
Course
BBN
Session
2
Role
Age
Sex
Other Information
3
50+
F
You
You have had no periods for some years and were surprised to have a bleed. Your
menopause has caused no problems and you think you’ve been quite lucky with this
compared to other women. You have an energetic and satisfying sexual relationship
You had some unexpected vaginal bleeding and attended your GP, Dr Johnson, about
it last week. She did a smear test and vaginal examination. She referred you to the
hospital to see a gynaecologist.
Now
You have come to the gynaecology clinic. You are anxious as your appointment came
through so quickly. When you saw your GP you did not discuss what the cause of the
bleeding might be.
You have had a pelvic and internal scan and a hysteroscopy (a small telescope passed
through the cervix or neck of the womb to look at the lining of the womb) and they
took a sample to test/biopsy.
You have got dressed and will now discuss the findings with the doctor.
Role player task.
Build up a social picture - partner’s name, jobs, family & hobbies.
Your elderly relative told you she had some bleeding after the menopause and she was
given some hormone cream. You hope that this will be the treatment for you as you
do not like hospitals.
21
Doctor Role
Patient’s Name Janice Hand
Setting
Hysteroscopy
Clinic
Course
Session/Role
BBN
2/3
You are a FY 2 in O&G.
Situation
Janice was referred by her GP, one week ago, with a history of postmenopausal
bleeding
The scan shows a normal sized uterus with thickened endometrium measuring 21mm.
Your consultant has just performed a hysteroscopy which has shown a suspicious
looking polyp at the fundus. Biopsies were taken. Unfortunately, the consultant has
been called urgently to theatre and you have been asked to explain the findings to
Janice.
Until you have the histology results you cannot give a diagnosis..
Role player task
You have not met this patient before.
You need to explain the position.
How are you going to tell her?
How do you start?
Note: If the histology confirms malignancy she will need an MRI scan to decide
further management (surgery or radiotherapy).
22
SP Role
Patients Name
Setting
Mr Alfred/Miss Ethel
Brown
Bed on ward
Course
Session
Role
Age
Sex
Other Information
BBN
2
4
65+
M or F
You are an elderly person, who was admitted to hospital with tiredness, weight loss,
constipation and poor appetite.
Past You have been on this ward now for two weeks. The staff are all wonderful, and
they are very kind to you. You have been unwell for 2 months and your tests have
shown a bowel cancer and you already know this. You are no better, in fact you feel
worse, have no appetite and you have lost more weight.
Now You are down today and feel worse. The doctors did not speak to you on the
ward round as you were half-asleep, but you saw them slip by. You know that you
have cancer and you are starting to realise that you will die because of this. You are
not scared of dying but don't want to be incontinent or lose control of your mind /
bowels (like your mother did. You nursed her at home).
As you have not made a will, by law your house and belongings will go to your
brother who you haven’t seen for years, but you want it to go to your nieces who have
been so good to you.
The young house officer has been looking after you. He/she comes to see you and
have a chat. You have had a good and friendly relationship. He/she sits down and
greets you. Make sure to ask for advice on this.
Role player task – for the students to realise that some patients do want to talk
about dying, and want a sympathetic and straightforward approach
Build up a social picture - names brother and nieces.
What were your mother's problems when she was dying at home and you were
looking after her?
You are usually a chatty, friendly person, but today you are grumpy and down.
You feel the doctors have avoided you when you wanted to talk about what is really
going on re your illness and prognosis.
You desperately want to talk about how you feel and if you are going to die. You will
ask the student about this almost as soon as he/she has sat down. You are not
embarrassed to talk about death, you see it as the final phase of life and would like to
have some dignity.
What are you going to say?
23
Doctor Role – please check gender of role player with your tutor
Patients Name
Setting
Mr Alfred or Miss
Ethel Brown
Bed on ward
Course
Session/role
BBN
2/4
You are a surgical F1 doctor
Situation. Mr or Miss Brown was admitted two weeks ago for investigation. This has
shown bowel cancer [stage IV – metastatic] which is terminal.
Mr or Miss Brown has anorexia, lethargy and weight loss and is deteriorating quite
quickly and is not fit for surgery. At the MDT meeting 3 days ago, it was decided no
further treatment should be offered and your consultant told the patient this news 2
days ago on the ward round. Mr/Miss Brown is dying but has not spoken to you about
this or about having cancer.
The Discharge Planning Team is liaising with social services and the GP/district
nurses to arrange support at home - this will include assistance with personal care
[toileting and bathing] and pain control.
Mr/Miss Brown has no children and lives alone. You have met the two young nieces
who are very supportive and visit regularly.
You like Mr/Miss Brown, s/he is chatty and easy to talk to. S/he appears to like the
nurses and appreciates the attention given in hospital.
The ward round has just finished. It did not stop at Mr/Miss Brown’s bed as s/he
appeared to be asleep and there has been no change anyway.
S/he is now sitting up and you pop over to have a chat.
Role player task
You are feeling quite cheerful. You are comfortable in Mr/Miss Brown’s company.
You go and sit down and ask how s/he is today.
You notice s/he is a bit down.
24
SP Role
Patient’s Name Timothy Taylor
Chris Taylor, son
Role
or daughter of
above
Setting
The hospital ward
office
Course
Session
BBN
3
Role
1
Age
Sex
Other Information
Up to 50
M/F
Past Your father Timothy Taylor has been attending the gastro-enterology clinic for
three years with troublesome indigestion and more recently weight loss. A
gastroscopy 6 months ago showed a small ulcer, which was treated. The symptoms
improved, but over the last two months he has been losing weight and has had more
indigestion pain, backache and nausea.
Now Your father had a clinic appointment this week and they decided to admit him
the next day for more tests (two days ago). He has just told you that he has incurable
cancer of the pancreas, which has spread to the liver. You are devastated. You stay a
while then leave Dad saying you are going home.
Your father looks awful, pale and uncomfortable. You can’t believe how ill he looks.
How can this be? He’s been attending the hospital clinic frequently. You can’t
understand what is happening or why. You are confused and upset. You are angry
with the situation and think the cancer was missed by the gastroscopy 6 months ago.
Cancer cannot come and make someone so ill in just 2 months.
You ask to see the doctor.
Role player task
What is your job, marital status?
What are your main concerns?
You are angry that your father told you the diagnosis and you were unprepared for
this. Shouldn’t the staff have told you first? Should he have been told at all?
What is happening? You are frightened that at this rate he will die soon and you feel
quite shocked and shaky inside.
NB Please be prepared to adjust the level of anger depending on advice from the
group tutor immediately before you join the group. Students feedback that they want
to practise talking with really angry/challenging patients/relatives.
25
Doctor Role
Patient’s Name Timothy Taylor
Interviewee
Chris Taylor, son
or daughter of
above
Setting
Hospital ward
office
Course
BBN
Session/Role
3/1
You are the medical F1 doctor
Situation
Mr. Timothy Taylor has been attending the gastro-enterology clinic for three years
with troublesome indigestion. A gastroscopy 6 months ago showed a small gastric
ulcer, which was treated with omeprazole.
The symptoms improved, but for two months he has lost weight and had more
indigestion, backache and nausea. He was admitted from clinic two days ago. A scan
shows incurable pancreatic cancer with liver metastases and repeat endoscopy shows
a tumour infiltrating the duodenum from the pancreas. The gastric ulcer has healed.
The patient asked for and has been told the diagnosis. It was his wish to tell his
son/daughter.
Mr Taylor has deteriorated in the last 24 hours and may die within a few days.
You have been asked to see the son/daughter of this patient. The nurse involved
explains that the relative is quite distressed.
Role player task
Who will be there?
How will you start?
26
SP Role
Session
BBN
3
Role
2
Age
Sex
Other Information
Up to 55
M/F
Course
Your name
Patient
Setting
Susan/Simon
Broadhurst
Mrs Broadhurst
[your mother
Ward 7 Dr’s office
Situation
Your mother (age 77) was rushed into the hospital casualty department tonight with a
tightness in her chest and severe breathlessness.
She saw her doctor about two months ago with chest pain, which was put down to
possible gallstones and she is waiting to see the specialist.
You visit the hospital and mum is now on ward 7, sleeping but she looks very pale.
You ask the nurses what has happened. The nurse is not looking after your mother but
says that she will ask the doctor, who is attending your mother, to come and talk to
you. You are invited into the doctor's office.
Role player task
Build up a picture of your family, job etc.
Your mother looks awful. You are naturally worried and upset
You want to know what the problem is, why the GP did not diagnose it before, and
why she is not on the CCU (Coronary Care Unit) if this is a heart problem – you
thought people with heart problems went to CCU.
You are firm, moderately angry, and challenging to the doctor about these things; you
want to know the answers – you don’t mind that she isn’t on CCU but you want to
check that she is having the best care [please note that people who are stable often
don’t go to CCU if they have a mild heart problem so not being on CCU can be seen
as a good thing!]. You are also anxious, talking a lot and ‘in the doctor’s face’.
NB: Please be prepared to adjust the level of anger depending on advice from the
group tutor immediately before you join the group [perhaps from 1 = mildly irritable
to 10 = violently angry!]. Students feedback that they want to practise talking with
really angry/challenging patients/relatives.
27
Doctor Role
Interviewee’s
name
Susan/Simon
Broadhurst
Patient
Mrs Broadhurst
[mother of
Susan/Simon]
Ward 7 Dr’s
office, you are the
Doctor on call
Setting
Course
Session/role
BBN
3/2
You are the medical F1 doctor
Situation
Mrs Broadhurst (age 77yrs) was admitted through casualty tonight with chest pain
which had been put down initially to gall stones. You saw her there and her tests have
shown that she has angina.
She is stable at present on therapy and sleeping after diamorphine for pain. Her BP is
normal [124/72], pulse regular 74/min. She is being monitored on ward 7.
Her son/daughter has asked to see someone and is in the doctors’ office. Nurse tells
you that Mrs Broadhurst is a widow, and that she has given permission for
information to be given her son/daughter who is named as her next of kin.
Role player task
How are you going to start the conversation?
Note: It maybe appropriate for patient to be on ward 7 if he/she is stable and would
only need transfer to CCU if she developed further problems or a myocardial
infarction
28
SP Role
Your Name
Setting
Patient
Louise Brooks
GP surgery
Steve Brooks, your
deceased husband
Course
Session
Role
BBN
3
3
Age
Sex
Up to 60
F
You are Louise Brooks, wife of Steve, who died on ITU 3 days ago.
Past Steve had had severe chronic bronchitis (or obstructive airways disease) for
some years for which he was under the care of Professor Woodcock at Wythenshawe.
His condition had worsened in the last four months and despite many warnings, he
continued to smoke. He was able, with considerable understanding from colleagues
and the headmaster, to continue his job as the live-in caretaker for a school in
Bredbury near Stockport, until his final illness which started about three weeks before
his death. You have no children and no family live nearby.
Steve got steadily worse at home, despite two visits from his GP and treatment with
steroids/nebuliser which normally helped. He was very poorly when eventually
admission was arranged. There was a three hour wait for a bed and the ambulance
then took another hour to arrive. When Steve did get to Stepping Hill Hospital,
Stockport, one of the doctors who was rushing around treating him commented that he
could not understand why Steve had not been admitted sooner.
Steve was sent up to a ward but within 12 hours deteriorated further and another
specialist said he needed to go onto the Intensive therapy Unit (ITU). Unfortunately,
there were no beds on ITU at Stepping Hill, so he ended up going to ITU in Bolton,
25 miles from Stockport and 35 miles from home, where he died 12 days later.
Getting to Bolton was a nightmare for you.
Now Your usual GP, who visited Steve twice pre-admission and arranged admission
on the second visit, is on holiday for the next 3 weeks. You have arranged to see
another doctor, who you haven’t met before, to express your anger about:
 The delay in arranging the admission – why was he kept at home so long?
– The hospital doctor obviously felt he should have gone in sooner.
 About the wait for a bed and then an ambulance
 About the lack of ITU beds at SHH
 You want the wording on the death certificate explained – it says:
Cause of death 1a bronchopneumonia
1b obstructive airways disease and emphysema
Role play issues: problems of travel to Bolton; nowhere to live now Steve is not
caretaker. Please be quietly angry initially and prepared to be sad [about the loss of
Steve] if the opportunity arises.
NB Please be prepared to adjust the level of anger or grief depending on advice from the group
tutor immediately before you join the group [perhaps from 1 = mildly irritable to 10 = violently
angry or extremely upset]. Students feedback that they want to practice handling strong emotions.
29
Doctor Role
Patient’s Name Steve Brooks
(deceased)
Mrs. Louise Brooks
Interviewee
Setting
Your GP surgery
Course
Session/Role
BBN
3/3
You are a GP near Stockport. Mrs Louise Brooks, who normally sees one of your
partners [now on holiday for 3 weeks], has booked to see you 3 days after the death of
her husband Steve.
Situation Steve had severe chronic bronchitis (or obstructive airways disease) for
years and was under the care of Professor Woodcock at Wythenshawe. His condition
had worsened in the last four months but he continued to smoke despite many
warnings.
Your partner saw him 3 weeks ago with another exacerbation of OAD, but Steve did
not respond to treatment which usually helped (antibiotics, steroids, nebuliser). Five
days later, on a second home visit, he was admitted to Stepping Hill Hospital,
Stockport [your DGH].
He died on ITU in Bolton 12 days later.
This is your second day back at work after your holiday. You have had a brief fax
from Bolton Hospital saying that Steve died 3 days ago but no cause of death was
given.
NB He was presumably transferred to Bolton due to lack of ITU beds at Stepping
Hill.
How are you going to start this conversation?
30
SP Role
Your Name
Setting
Patient
George/
Georgina Martin
Hospital outpatient
Clinic
Your mother Mrs.
Edith Martin
Course
BBN
Session
3
Role
4
Age
Sex
Other Information
Up to 60
M/F
Setting - hospital outpatient clinic - you ask to speak to the doctor whilst mother
is having blood taken
Your mother Edith lives alone. She is fairly well - her arthritis has slowed her down a
bit, but she still cooks and shops for herself. She is very independent and looks after
herself. She does not drive so you have brought her to the hospital today for an out
patient appointment. You are very fond of your mother and wanted to bring her to the
clinic. You run your own business i.e. you are self-employed.
She found a breast lump (you haven't seen it) and her GP suggested that she saw the
breast specialist. She had tests done one week ago - a mammogram and a biopsy. You
have come for the results.
You ask to see the clinic doctor in the hospital before he/she sees your mother.
You are worried that she may have breast cancer and think that she wouldn't cope and
would give up. You do not want the doctor to tell her it is cancer.
Role player task
What is your name?
Why won't mum cope if it is cancer? List two or three reasons for this belief.
What are you going to say to the doctor?
You have asked to see the doctor whilst your mother is having some blood tests.
The clinic doctor is not the one you saw before.
Although you don’t want mum told, you must be prepared to compromise with the
doctor/student after you have tried to manipulate the doctor/student to get your way.
31
Doctor Role
Patient’s Name Mrs. Edith Martin
Interviewees
George/ Georgina
name
Martin, son or
daughter of above
Setting
Hospital outpatient
Clinic
Course
BBN
Session/Role
3/4
You are the F2 doctor in the breast clinic.
Setting - hospital OP clinic – son/ daughter has asked to speak with you
Mrs Edith Martin is an elderly lady who lives alone and is attending clinic for the
results of tests following her first appointment last week. The referral letter from her
GP stated that he suspected breast cancer.
She had tests done last week, results now in: a mammogram which shows an 8cm
breast mass and a breast biopsy confirming cancer.
The consultant, who is on holiday today, has written in the notes ‘Too big for surgery
in first instance. To start tamoxifen and reassess in 4 weeks’
She is an independent lady with full mental capacity who manages well and looks
after herself despite having arthritis.
Today, she is having some blood tests. Her son/daughter has asked to speak to a
doctor and the nurses have asked you to see her son/daughter.
The consultant, who is on holiday today, has written in the notes ‘Too big for surgery
in first instance. To start tamoxifen and reassess in 4 weeks’
(THE DIAGNOSIS HAS BEEN SHARED WITH THE PATIENT OR
RELATIVE)
She is an independent lady who manages well despite having arthritis.
Role player task
You have no idea why s/he wants to see you.
You were not in this clinic last week.
How are you going to start the conversation?
32
SPIKES - a protocol for breaking bad news
Breaking Bad News - handout week 1
S
Setting and listening skills setting: physical space; privacy; same level, no
physical barriers, bleep off, avoid interruptions, clarity on time available, listening:
body language; eye contact; open questions; pauses; silences; nods; smiles,
reflecting, clarifying, use of touch may help if touch a non-threatening area ( arm,
forearm) and you and the patient feel comfortable
P
Patient’s perception of the condition and its seriousness: - ask patient what
he/she knows/suspects already, listen to their response to gauge comprehension, is
there a mismatch between medical information and their perception?
I
Invitation check if the patient wants to know details of diagnosis and/or
treatment. ‘Are you the sort of person who..?’
K
Knowledge give the facts in small chunks using suitable language i.e. the step
approach, start at the point the patient is up to, check understanding at each chunk,
respond to the patient’s reactions
E
Explore emotions & empathise give an empathic response by identifying the
emotion, identify the cause and respond in a way that shows you have made a
connection between the two e.g. ‘I can see this is unexpected news that has
shocked you.’ This skill helps the patient to begin to come to terms with the news.
S
Strategy and summary suggest a strategy based on the medical facts and the
patient’s expectations; assess the patient’s response; agree a plan
summarise the main points; check if this agreed and if there are any omissions;
agree a clear contract for the next contact
RECOMMENDED READING
Baile W, Buckman R et al. SPIKES - a six step protocol for delivering bad news. Oncologist
2000; 5[4]: 302-311.
Available online via theoncologist.alphamedpress.org
Buckman R. Breaking bad news: why is it so difficult? BMJ 1984; 288: 1597-1599.
Buckman R. How to Break Bad News. Papermac, Basingstoke, 1992.
Buckman R. I don’t know what to say - how to help and support someone who is dying.
London, Pan Books, 1996.
Lugton J. Communicating with dying people and their relatives. Radcliffe Medical Press ,
Oxford, 2002.
Maguire P, Faulkner A. Handling bad news & difficult questions. BMJ 1988; 297: 907-909.
33
Breaking Bad News: The Importance of Hope.
Week 2 handout
The care of the patient needs to be multi-layered addressing their physical,
psychological, emotional and social needs. With terminal illness it is important to
work with the patient’s needs on all these levels and vital to create a climate of hope.
Kreiger (1982) described four phases of a terminal illness and the hopes the patient
may have during each:
1. In the first phase the patient hopes that there has been some kind of misdiagnosis
or that the illness will turn out to be curable.
2. As time passes patients move to the second phase where hope for successful
treatment predominates.
3. People may move to a third phase of hope when they are told that nothing more
can be done to cure them. Hope is then focussed on prolongation of life.
4. Finally hope for a peaceful death is the main concern. Hope becomes centred on
the relief of physical symptoms, the maintenance of dignity and the wish to be
loved and forgiven. Hope for some kind of afterlife may form part of this final
5. phase.
Lugton states that the attitudes and actions of health professionals can create a climate
of hope for patients. Herth found that having one’s individuality respected helps to
facilitate hope.
Listening to patients and their relatives is the vital communication skill for a doctor in
gauging the right amount of information for this individual, at this time.
Inappropriate information or too much information can remove a person’s hope. The
skill is to listen and discover the anxieties so that they can be alleviated and addressed
truthfully, without leading to despair. Buckman (Buckman and Kason 1992) suggests
the phrase: ‘We’ll plan for the worst but hope for the best’. Here information is
neither totally negative nor falsely reassuring. Short – term goal setting and planning
with patients to use their time to achieve what they want helps to foster hope.
Psychological and psychiatric morbidity have been linked to situations in which
patients’ concerns remained undisclosed and unresolved Parle et al. To be able to
address the concerns of patients requires self- awareness from the doctor of their own
attitudes to death and bereavement. Often health professionals ‘block’ patients’
anxieties by changing the subject, not hearing or responding to cues and focussing on
the physical aspects of care. There are training courses available for health
professionals to develop their skills in communicating with patients with a terminal
illness e.g. run by Christies Hospital.
References
Buckman R 1992 How to Break Bad News, Papermac, Basingstoke
Herth K Fostering hope in terminally ill people, Journal of Advanced Nursing 15 (11):1250 1259 (1990)
Kreiger D 1982 The Renaissance Nurse Harper and Row, New York
Lugton J 2002 Communicating with dying people and their relatives Radcliffe Medical Press,
Oxford
Parle M, Jones B & Maguire P 1996 Maladaptive coping and affective disorder among cancer
patients Psychological Medicine 26 (4) 735 -44
34
ANGER



Breaking Bad News - handout week 3
is a normal part of loss and grieving
is around a lot in health care
people may be angry – with us/with others/with the system/with their illness
Your communication skills will affect the outcome
Signs
Speech
Facial expression
Manner
Body language
becoming louder, quicker or more quiet
changing, flushed, reduced eye contact
impatience, non-compliance
closing in, sudden expansive movements
You need to break the cycle of aggression
 stop
think
 do nothing that may escalate a threat of violence
 try to understand the reasons behind the anger
 be prepared to discuss this with them
If you are confronted by an angry patient, try to:
- be at their eye level
- be polite and firm
- acknowledge their feelings
- be willing to talk and listen – open questions
- create a calm atmosphere
- verbally break the cycle of anger and aggression
Do not
- behave in a threatening way
- take personal offence at anything that may be said
- interrupt an outburst or contradict the patient
- caution their choice of words
- become combative or threatening
- make promises that cannot be kept
Do
- remember it is the patient/relative who is angry, not you
- take any threat of violence seriously
- have a colleague nearby
- have an ‘escape route’ yourself & leave them an ‘escape route’
- keep on your guard until the incident is over
- be ‘street wise’ e.g. don’t work alone, jewellery etc
- use the security guards if necessary but under your supervision
35
Talking with relatives -Breaking Bad News - handout week 3
Assess:



information about family and friends
patient’s views on the quality of the relationship
social support
Consider family beliefs and influence:
 previous personal experience of illness
 previous experience of illnesses in family and friends
 beliefs of patient or their family
 ‘sick role’ within the family
When listening to relatives:
 hear their thoughts/feelings/expectations
 acknowledge their support
 give them time and privacy
 arrange a method of contact
 give information to the patient first
 find out which relatives can be told what information
 always write any important discussions with relatives in the notes
 do not examine patients/perform procedures in front of relatives – except children
Secrets: may be different levels -individual/internal/shared
 fear creates secrets and prevents discussion
 check your role
 discuss with your team
 consider ethical/legal /confidentiality
 a general discussion with the patient may sort it out
 try using hypothetical questions/possibilities with out breaking confidentiality
Collusion – a conspiracy (spoken or unspoken) to maintain a mutual pretence
‘The task of the health professional is to act as an arbitrator’ Maguire & Faulkner 1988
You might:
 ask one of the colluding parties for permission to check the other’s level of
awareness
 tell the relative that the patient is your first responsibility – if they want
information, it will be given this risks being confrontational
 check your patient’s level of knowledge or suspicion – be prepared to confirm
these suspicions – get your patient’s permission to inform the relative of this.