Breaking bad news

Breaking bad news to patients is one of the most difficult parts of being a medical professional, but is also an essential skill not only for oncologists and palliative care staff, but also for obstetricians and gynaecologists. Miss Cass and Miss Kaushik, describe what skills are necessary for breaking bad news in the most effective and understanding way.

Introduction

Breaking bad news is an integral skill required by all those interacting in the healthcare environment. The initial aims of a clinical consultation are to build a rapport and ensure support to the patient, and extend that to the family. This is particularly important when discussing a cancer diagnosis, or disease progression or recurrence. Regardless of whether medical improvement is possible accomplishment of the aforementioned goals may help with some improvement of subjective symptoms. Hence, effective communication can change the way a patient feels about a clinical outcome and is therefore an important determinant of satisfaction with care. Poor communication of bad news to a patient and relatives can have a significant distressing impact not only on those receiving it, but also on the healthcare professional divulging it.^1,2 Breaking bad news can be particularly stressful for an inexperienced clinician, for younger patients or when prospects for treatment are more likely to be palliative,³ and it has been demonstrated that the bearer of bad news experiences anxiety and a burden of responsibility.⁴

Bad news

The definition of bad news is a broad one. Traditionally bad news constitutes a sinister diagnosis such as cancer or progression and recurrence of a chronic disease or one that seriously adversely affects the patient’s view of her future. More benign information, such as rescheduling of surgery or delays in service provision, may require similar skills in communication to enhance the patient’s experience and perception of healthcare services.⁵ This article focuses mainly on the former situation where the bad news comprises a significant longer-term impact on the patient and relatives. Bad news often threatens a patient’s identity and can challenge spiritual and emotional feelings. It may impact on a much wider network of life and society than only on the individual patient alone. The way in which bad news is communicated to the patient and relatives can influence the acceptance and subsequent management of the problem faced.⁶ Clear, sensitive communication of relevant information by trained clinicians in an appropriate environment may enhance the patient journey through a difficult time. This is not only important at initial diagnosis of a disease, but throughout the management process and in the event of progression or recurrence. It is therefore imperative that this is an expertise that is given as much thought, time and training as all the other clinical skills required to be a competent healthcare professional. An important and related issue is one of medico-legal implications. The majority of complaints against health practitioners have arisen from failures in communication.⁷ Therefore, good and effective communication is required to ensure informed consent, involving the family in the care of the patient, reducing the uncertainty associated with a new or recurrent illness and increasing recruitment to clinical trials.

Methods and protocols

Breaking bad news relies upon close attention to the setting, words and attitude with which news is given. There has been much research into important methods in communicating bad news and many guidelines exist to facilitate clinicians. However, assessment and awareness of the patient as an individual means that information and communication should be tailored to the specific circumstances and needs of the patient. A six-step protocol (SPIKES) has been suggested to support clinicians in delivering bad news by incorporating important communication techniques and strategies for addressing a patient’s distress.⁸ The step-wise approach provides guidance for clinicians in difficult circumstances. The initial step involves creating a comfortable environment, using appropriate body language and conducting a mental rehearsal of the consultation. Assessment of the patient’s perception of the situation and ascertaining their desire for the extent of information is suggested to lessen the anxiety associated with divulging bad news. A ‘warning shot’ prior to giving the information is described (step four). The latter steps of the protocol involve addressing the patient’s emotions with empathetic responses and summarising and creating a strategy for how to proceed.⁸ This approach may support and reduce potential psychological consequences from poor communication in a situation where expertise is required. Although a helpful aid, a dynamic interaction guided by patient understanding and behaviour is more likely to address inevitable differences among different patient groups.⁸

Easing delivery of bad news

Research with patients and relatives has further highlighted key domains that are preferable, to ease the delivery of bad news.⁹ Content of information with appropriate expertise of the clinician, emotional support and a suitable time and location have again been shown to be important factors.¹⁰ A study investigating the perception of a group of cancer patients to a consultation where they received bad news indicates that satisfaction was predicted by elements related to the environment, to what was said and to how the news was delivered.¹¹ Additionally the study suggests that statistically significant independent predictors of patient satisfaction were associated with a comfortable environment, abundant time for the consultation with plenty of time afforded to listening to the concerns of the patient and the ability of the physician to empathise with the patient’s experience.¹¹

Setting

An appropriate environment for breaking bad news, although not always achievable particularly in an emergency situation, enables the patient, relative and clinician to be comfortable and free from interruptions. Practically, the room should be large enough for relatives, and it should not house physical barriers.¹² Allowing enough time to ensure the patient is not rushed in assimilating the information, asking for clarification when needed and inviting questions is important in planning the time and place for relaying news.

Friends and coworkers

Furthermore, arrangements for the patient to have a companion of their choice present at the time of breaking bad news should be aspired to, and relevant information about the diagnosis or facts surrounding it should be readily available or signposted during the consultation. The presence of an allied healthcare professional enhances and reinforces such information sharing. Ideally the person conveying news should be known to the patient already. Use of written information or illustrations are helpful for after the consultation.⁵ It has been suggested that recordings can be beneficial as the patient often retains very little of the information.¹³

Effective communication

Interactive and open communication between a healthcare professional and patient is also critical to allow emotional support and compassion.¹² The sensitivity of the clinician and the ability to discuss difficult topics such as death and dying are important factors in effectiveness.¹² A patient-led approach to breaking bad news based on these factors is another well recognised and recommended technique.^2,14-15 Assessment of the patient’s understanding of events leading up to the consultation where bad news is given enables the clinician to begin at an appropriate stage in the patient journey. The rate at which information is given and the details included are led by the patient, and open questions allow concerns and anxieties to be addressed and explored thereby facilitating the interactive process.⁶ This method of ‘packets’ of information enables the clinician to tailor delivery of information to the patient’s needs and readiness to receive it.¹² Reflecting or repeating a patient’s phrases and aiding patient understanding are techniques that have been described to aid discussion of particularly distressing topics. Summarising key facts of the consultation has been shown to improve patient understanding and reduce confusion.¹²

Feelings

It has been demonstrated however that doctors overestimate their ability to effectively identify aspects of patient distress when breaking bad news.¹⁶ A qualitative study of oncologists demonstrated that doctors were frequently unable or ineffective in recognising, addressing and managing patients’ feelings.¹⁶ These feelings or emotional responses to bad news can be vastly variable and on occasions unexpected or delayed. In fact, it can be argued that breaking bad news is in some way the simplest part of a consultation. Responding to the patient’s reaction and subsequent questions can be even more difficult and uncomfortable, particularly for the inexperienced.

Five stages of grief

The well-known Kübler-Ross model or five stages of grief hypothesis involving denial, anger, bargaining, depression, and acceptance can be related to any event or grief process where a patient is exposed to bad news.¹⁷ Although this model was inspired by work with terminally ill patients there has also been some criticism about its prescriptive nature and that not every individual goes through this scheduled process. Nonetheless, patients may express fear, denial, anger, sadness, frustration and shock instantaneously on receiving bad news, either in isolation, or as varying combinations. It is paramount that clinicians have the ability to identify and manage these emotional responses at the time and as they develop. If these essentially normal and appropriate emotions are not managed, they may negatively impact the patient’s ability to manage the news in the long term. For example, often a patient may ask ‘why me?’ and although this question is impossible to answer, clinicians must respond and encourage patients to reflect and find meaning in their diagnosis to find a sense of control and understanding.¹⁸ Acceptance of bad news for some may be swift. However, for others it may be hindered by guilt, shame or fear. Exploring these issues can help the patient to embrace the effects the news may have and potentially accept it, thus allowing them to adjust their lives accordingly.

Passion for life

It has been suggested that bad news can transform a patient to become stronger and discover a passion for life, even in the case of impending death.¹⁹ A clinician has an important role in this personal event by encouraging patients to search for how good can come from bad.¹⁸ This may involve religious, spiritual methods or listening and talking about past encounters or hope. Beyond breaking bad news, the spiritual and emotional issues of the patient must continue to be addressed. It is argued that clinicians focus more heavily on relieving physical symptoms and pain compared to emotional distress and suffering.¹⁸ The ability to recognise and explore the psychological consequences of receiving bad news and addressing the patient’s concerns, significantly impacts on the capability of the patient to adjust to the news, and reduces longer-term anxiety.^5,20-22 Furthermore, it has been suggested that the patient’s appraisal of the information and the personal resources available to support them impact her ability to cope with bad news.⁵ These key techniques of engaging the individual patient’s needs, mean that the clinician breaking bad news can positively influence the outcome. Moreover, open listening and reassurance of non abandonment have been shown to have a positive impact on the patient’s ability to face the challenges of bad news, particularly at the end of life.²³

Personal strength

Work by Cassel and others has demonstrated an effective set of responses to ease patient suffering.¹⁸ Personal strength of a patient enables them to deal with bad news. ‘Inquiries’ into a patient’s beliefs and opinions, personal relationships, strategies for coping, resources and desires may enable a clinician to elicit a patient’s true concerns. ‘Prescriptions’ of resources, referrals or reading materials can then be tailored to achieve these specific patient goals, and care can be planned and focussed accordingly. This method allows the individual’s particular circumstances to be addressed and enhances a mutual trust and compassion in the relationship between clinician and patient. Revelation of bad news can also threaten a patient’s feelings about their future. Encouraging the enjoyment and living in the present can enable patients to avoid the worry of a future constrained by darkness of a poor prognosis.¹⁸ Identifying patients’ views as to what is important to them allows them to partake in activities they wish to do in the present, and to plan ahead. Although at an initial consultation of bad news many of these areas are not the main focus, they must not be forgotten in forthcoming meetings. Ongoing assessment of patient needs and feelings should be readdressed at every opportunity, particularly when bad news is revisited or renewed.

Beware giving false hope

It has been suggested that providing patients with a sense of hope after breaking bad news can help to enhance relationships and create support.¹⁶ The feeling that events will turn out for the best, or that of anticipation are some descriptions of what hope means. Hope for patients with a poor prognosis may have different meanings, such as feeling empowered or like they have control over death. Although hope should be given to all patients when bad news is broken, the critical part is the pledge of support and the promise that all that can reasonably be done will be done. False hope or optimism can be unfair and harmful, and it may disrupt the trust between clinician and patient. Honesty, therefore, is imperative to enable patients to establish their own sense of hope, and the aspects of care and treatment that are crucial to them. The impact of bad news on more practical aspects of life are also important to consider. Bad news can precipitate overwhelming problems for patients and relatives and these should be established. Involvement of social workers or specialist nurses can facilitate prioritisation of these issues and support patients in resolving them. Open access and defined follow-up, whether for further counselling or instigation of treatment, should be set at the end of the consultation to create a sense of control and support.

Conclusion

Breaking bad news is undoubtedly one of the most challenging communication skills for any medical professional. However, it is often neglected in training with focus on those professionals working in oncology. As described, the perception of what is bad news varies considerably and is encountered by most clinicians and patients at some point in their career or life. Training over an intensive three-day course has been shown to improve physicians’ abilities to communicate bad news and many similar courses exist.² Yet, little emphasis is placed on this expertise outside the world on oncology and palliative care, despite it being a vital skill that requires practice, nurture and feedback. Setting the scene, understanding a patient’s views and feelings, and exploring psychological consequences of bad news whilst maintaining hope are some of the important skills for clinicians breaking bad news. In conclusion, breaking bad news well is fundamental to a patient’s experience. However, it is managing its consequences that is imperative. Although clinicians cannot answer every personal question a patient may have, they play a role in a partnership that is present throughout the process.¹⁸ Breaking bad news is a dialogue between clinician and patient that requires both to have a personal strength and faith in their relationship beyond the fear and uncertainty of the disease. Whether this relationship involves being present for a patient at the initial shock of bad news or accompanying them through their journey, witnessing their suffering or enabling meaning and focus in her life, it is arguably one of the most demanding skills for a clinician, but is also perhaps the most privileged part of clinical work.

Authors

Miss Gemma K S Cass is a trainee in obstetrics and gynaecology at Musgrove Park Hospital in Taunton. Miss Sonali Kaushik MRCOG is a subspecialty trainee in gynaecological oncology at Cheltenham General Hospital.

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