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Breaking bad news - Part 2 |
Bad news can be defined as any information that drastically alters a patient’s view of the future for the worse.
A patient has a right but not a duty to hear bad news.
Most patients want two things:
1. A certain amount of information (the right amount)
2. The opportunity to talk and think about their situation (ie. a therapeutic dialogue).
As outlined in the previous article, breaking bad news is important to maintain trust between the patient and doctor, to reduce uncertainty, to prevent inappropriate hope, to allow appropriate adjustment, and to prevent a conspiracy of silence that destroys family communication and prevents mutual support.
Breaking bad news can be broadly broken down into six steps.
1. Preparation
2. Ask questions to start the negotiation.
3. Explain in steps.
4. Elicit concerns and feelings.
5. Summarise
6. Offer availability and follow up.
1. Preparation
a) Know all the facts, ie. what has happened before and what the management options are.
b) Who should be present. It is often best for a doctor and nurse to see the patient and relative together. The patient should be given the opportunity to have a relative present as they may be in a state of shock.
c) Set time aside and avoid interruptions and always sit down.
2. Ask questions
It is important to hear the patient’s narrative of events to allow them to explain what has happened and where they are up to in their illness, eg. ask “How did it all start?” and “What happened next?”
A useful question can be “What has been the most difficult part of the whole thing for you?” This way you understand the patient’s perspective and what they understand by their illness and therefore can avoid giving shocking information, if, for example, it is their belief they have had curative treatment when you know that their prognosis is only weeks.
There is good evidence that most doctors interrupt the patient within 30 seconds of speaking.
3. Explain if requested
Eg. Ask “Do you want me to go over anything?” The aim is to narrow the information gap. The skill is finding the optimum level of information to reduce uncertainty without causing fear by giving excessive information.
- Be clear and simple.
- Use kind words.
- Give a narrative of events guided by the patient’s earlier narrative of events using the same language.
- Avoid medical jargon.
- Check understanding (“Is this making sense?” “Have I covered what you want to talk about?”).
- Be as optimistic as possible.
- Deal with concerns before explaining details.
Denial is a way of coping with fear and it should be respected as a coping strategy, especially if the patient is coping. If the patient declines further information, it should be acknowledged, but also acknowledge the discomfort of uncertainty and give permission to ask questions at a later date. Few patients adopt a stance of denial permanently, most start to ask for more information once they feel more secure. Patients usually experience belief once they are able to discuss some of their fears.
4. Elicit concerns and feelings
After explaining bad news eliciting concerns is essential. Ask “What is worrying you the most?” Many patients are distressed but can be uncertain what the distress is mainly about. Giving permission to discuss concerns enables the patient to start clarifying the issues and then prioritising their concerns. This feels like a positive process to the patient and is always helpful. Avoid premature reassurance or excessive explanations, which can cause dissatisfaction and frustration.
Allowing ventilation of feelings provides a therapeutic part of the dialogue. ‘How does this leave you feeling at the moment?’ is the key phrase. The aim is to help the patient try to name their feelings. Encouraging the ventilation of feelings conveys empathy. Empathy means trying to understand what the patient is feeling, which is much more therapeutic than sympathy (feeling sorry). Our own discomfort during this stage can have an impact on the therapeutic process especially if powerful feelings emerge such as fear, anger. Stay calm and allow time for the person to think about their feelings.
5. Summarise
Summarising is a useful process for patient and doctor. It is supportive and reduces the patient’s feeling of confusion at a time of crisis. Making a plan involves a lot of thought and has to integrate the patient’s main concerns with the doctor’s knowledge of the management options available. It also acknowledges the support system already available to the patient, especially friends and relatives. It helps to explain that it is possible and important to simultaneously prepare for the worst and still hope for the best.
6. Offer availability
Follow up is important for three reasons:
a) The details of the information are not remembered at first, rather the way the information was given.
b) Emotional adjustment takes time.
c) It is an opportunity to see other family members/supporters.
Conclusion
It is not always easy to remember the six steps when breaking bad news to a patient. However the principles essentially follow two unbreakable rules when breaking bad news.
1. Ask questions first - What is known? What is wanted? Should relatives be involved?
2. Elicit concerns and encourage the ventilation of feelings.
If you do this you will help your patients and not do any harm.
The above article was based on “Breaking Bad News (Pocket Book)” by Peter Kaye, EPL Publications. The book is extremely useful as a teaching aide and is not available from bookshops. It is available from EPL Publications, 41 Park Avenue North, Northampton NN3 2HT UK. Any queries/comments to Joanne Doran.
20 Feb 2002
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