bad news

• Breaking Bad News


  A practical approach
• Health Psychology & Human Diversity
• Dr. Kareem Nasir Hussain Al- Esawi

  F.I.C.M.S, C.A.BM.M.R.C.PSYCH, Consultant psychiatrist
• Buckman 1992: 'If we do it badly , the patients or family members may never forgive us , but if we do it well , they may never forget us'
• Bad news


  Any information that drastically alters a patient's view of their future for the worse
• Bad news is not always entirely bad
• Determination that the news is entirely 'bad' is for the most part in the mind of the perceiver and may vary according to personal circumstances
• Factors that may affect perception of bad news include age and familial obligations
• Disclosure


  It is important to inform the patient when the diagnosis is confirmed
• There is a move towards greater openness in the communication of information about life threatening illness
• In the UK 95% of GPs disclose cancer diagnosis

  
• GMC guidelines (2004)


  Patients have a right to get information about any condition or disease from which they are suffering. This should be presented in a manner easy to follow and use, and include information about diagnosis, prognosis, treatment options, outcomes of treatment, common and/or serious side-effects of treatment, likely time-scale of treatments and costs where relevant. Doctors should respect the wishes of any patient who asks them not to give detailed information.
• Why is it important to tell patients when there is bad news?

  • To maintain trust
  • To reduce uncertainty
  • To prevent unrealistic expectations
  • To allow appropriate adjustment
  • To promote open communication
• Doctors find it easier to treat and care for patients if they know their diagnosis
• Lack of information can increase patient uncertainty, anxiety, distress, & dissatisfaction
• Most patients wish to know their diagnosis, and be informed about the progress of the treatment and disease
• 96% cancer patients wanted to know diagnosis; 91% wanted to know chances of a cure; 79% wanted as much information as possible

  
• Some patients, especially those with a poor prognosis may not want all the details
• Patient and relatives may differ in their need to know
• Collusion


  A secret agreement made between clinicians and family members to hide the diagnosis of a serious or life-threatening illness from the patient
• Reasons for collusion include desire to protect relative and protect self from discussing difficult issues with patient, and belief that truth may take away patient's hope
• Patients have a right to make decisions about their own care; it is unethical to keep truth away from patients if they are ready to face it
• In the UK, Northern Europe, North America, Australia almost all cancer patients are told the truth, with exceptions for young children and those with cognitive impairment
• The open approach is not practised in all cultures - Southern & Eastern Europe and parts of Asia, where illness may be viewed as shameful, it is deemed cruel to tell patient, or it is considered dangerous to talk about prognosis and to name the illness
• It is not easy to break bad news
• Why is it difficult to break bad news?

  • Empathy for patient, own reactions, practical constraints
  • Unleashing powerful emotions/fear of patient's reaction
  • Desire to 'protect' the patient
  • Fear of being blamed: shooting the messenger
  • Lack of confidence in ability to communicate
  • Sense of failure as a doctor
  • Feeling embarrassed about how to offer comfort
  • Reminders of own mortality / family & friends
  • Lack of time
• Inadequate communication may be the source of much distress for patients and their families and mitigate against adjustment to cancer and other life threatening illnesses
• If bad news is not delivered well this can have an impact on emotional well-being e.g. distress and depression, and adjustment to and ability to cope with the illness, for patients and their relatives
• There is no universally agreed guidelines on how to break bad news, although there is a general consensus
• Most patients expect full disclosure delivered with empathy, kindness & clarity
• Key guidelines for breaking bad news

  • 10-step approach (Kaye)
  • S-P-I-K-E-S (Buckman)
  • Consensus guidelines (Girgis & Sanson-Fisher)
• Preparation


  • Break the bad news face-to-face, not over the telephone / in a letter. Avoid informing relatives first
  • Ensure privacy & no interruptions, allow enough time
  • Find out who the patient wants present
  • Introduce yourself and any colleagues (no more than 3 staff)
  • Sit down, eyes on same level - eye contact. No physical barriers-computer etc. Tissues available
• What does the patient know?

  • Assess patient understanding
  • Use facilitating behaviours
  • Listen to language used by patients
• Breaking the news


  • Use a warning shot
  • Direct patient to diagnosis
• Responding to patient needs

  • Explore how much information patient requires
  • Be optimistic/positive
  • Listen to patient's concerns, allow emotional response
• Concluding the consultation


  • Discuss strategy, agree on a clear plan
  • Summarise the main discussion topics
  • Signal closure and ask if there are any important issues that should be addressed before the interview ends (written information?)
  • Offer future availability and information
  • If the patient is still distressed ask if they would like: a member of the health care team to remain, someone contacted, or to be left alone
• The SPIKES Protocol


  • S - Setting and listening skills
  • P - Patient 's Perception
  • I - Invitation from patient to give information
  • K - Knowledge – giving medical facts
  • E - Explore emotions and empathise as patient responds
  • S - Strategy and Summary
• Documenting the Consultation should include: patient's name, consultation location, date, who was present, what the patient has been told, what the patient replied, treatment options if discussed, list of health care professionals to be informed/contacted, strategy, name, seniority, signature of bad news breaker