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