Breaking Bad News

Define bad news, and describe situations that fall into “breaking bad news.”
One definition of bad news is “any news that that drastically and negatively alters the patient’s view of her or his future.” Bad news is most commonly associated with a terminal diagnosis but it is defined by the patient so it could be almost anything.

Examples of breaking bad news situations:
 * Pregnant woman’s ultrasound confirms fetal death
 * Patient’s MRI confirms multiple sclerosis
 * Adolescent polydipsia and weight loss end up being the result of diabetes
 * Parents learn that their son has moderate asthma
 * A child needs a routine immunization (yes, this could be perceived as bad news)

Describe a systematic approach to breaking bad news
Rabow and McPhee model for delivering bad news-ABCDE model

A-Advance preparation

 * 1) Familiarize with the relevant clinical information (including people's names...duh).
 * 2) Arrange for sufficient time to discuss the news and find a private location to do so.
 * 3) Mentally practice how you will give the news.

B-Build a therapeutic environment/relationship

 * 1) Find out what the patient wants to know (what they want to know and how much)
 * 2) When possible, have family members or other supportive persons present.
 * 3) Introduce yourself to everyone present and learn names and relationships to patient.
 * 4) Foreshadow the bad news, “I’m sorry, but I have bad news.”
 * 5) Use touch when appropriate. Keep in mind that some patients or family members might prefer not to be touched.
 * 6) Assure the patient that you will be available. Schedule follow up meetings.

C-Communicate well

 * 1) Ask what the patient or family already knows and understands. One source advises “Before you tell, ask…Find out the patient’s expectations before you give the information.”
 * 2) Speak honestly but kindly and compassionately. Avoid euphemisms and medical jargon. Use the words cancer or death.
 * 3) Allow silence and tears and avoid talking to disguise your own discomfort. Proceed at a pace that is comfortable for the patient.
 * 4) Have the patient tell you their understanding of what you have explained.
 * 5) Be aware that the patient will not retain much of what is said after the bad news is given. Write things down, use diagrams and repeat important information.
 * 6) At the end of each visit, summarize and make follow up plans.

D-Deal with patient and family reactions

 * 1) Assess and respond to emotional reactions.
 * 2) Be empathetic; it is appropriate to say “I’m sorry” or “I don’t know.”
 * 3) Do not argue with or criticize colleagues; avoid defensiveness regarding your, or a colleague’s, medical care.

E-Encourage and validate emotions

 * 1) Offer realistic hope.
 * 2) Explore what the news means to the patient.
 * 3) Use interdisciplinary services to enhance patient care, but avoid using these as a means of disengaging from the relationship.
 * 4) Attend to your own needs during and following the delivery of bad news. Issues of counter-transference may arise, triggering poorly understood but powerful feelings.

Another approach (perhaps just semantically different) advocated by Dr. Link breaks down the process into 4 steps:
 * 1) Invest in the beginning
 * 2) Elicit parent/patient perspective
 * 3) Show empathy
 * 4) Invest in the ending

Challenges

 * Not being aware that news are bad
 * Fear of upsetting the patient
 * Lack of systematic approach
 * Provider's Own emotions can complicate things
 * Cultural barriers/language
 * Not sure how to respond to patient’s reaction (eg crying, yelling, stoic, etc)
 * Unsure about the prognosis/diagnosis (clinical uncertainty)

Solutions

 * Use a systematic approach (see above)

Set specific short and long term communication skills goals.

 * Up to individual students