Case studies and articles
Estimated read time: 7 mins
Breaking bad news can be a daunting task for many physicians.
For those working in a specialty such as palliative care the task of delivering bad news happens frequently. In other specialties breaking bad news may be less common but all clinicians will carry out these tasks at some stage in their careers.
In many cases the experience of breaking such news may fall to a very junior member of a clinical team.
Kimberley RM et al reveal that 91% of respondents in a questionnaire perceived delivering bad news as an important skill but only 40% felt they had the training to deliver such news.
Bad news may not always be about death or cancer. It is any information that alters a patient’s expectations of their future. In reproductive medicine it may be devastating for a couple to find out that the male partner has azoospermia or that a female patient has POI (premature ovarian insufficiency). In just a couple of minutes their dream of a future child is dashed.
Let us reflect on one example of breaking bad news and reflect on what could have been done differently.
Case studyMrs V is aged 36 and attended the emergency department eight weeks ago with significant abdominal pain and a prior history of ovarian cysts. At that presentation she was examined, an ultrasound scan was ordered, blood tests were carried out, and she was discharged with a decision for an outpatient appointment. Mrs V works as an allied health care professional in her local hospital. One evening she was in the supermarket checkout queue, accompanied by her young daughter, when her phone rang. She recognised the number as that of the hospital. On answering the call Dr X introduced herself as a member of the ED team and stated that Mrs V needed to attend the hospital in the morning as her blood test results were abnormal and a consultant needed to meet her to plan her care. Being somewhat knowledgeable about clinical matters Mrs V asked what tests were abnormal and Dr X replied: “Your tumour markers are raised but the consultant will explain everything to you in the morning.” Mrs V was distraught and started crying uncontrollably. Her young daughter was so upset to see her mother in this state and also started crying. Mrs V felt everyone was staring at them, dropped her basket and ran out of the supermarket. She drove home but has no memory of that journey. Her family were beside themselves that night. Thankfully, Mrs V’s sister, who works as a nurse was able to attend the appointment with her the following morning and the consultant gave them some reassurance. However Mrs V still believed that cancer was a possible diagnosis based on her experiences the night before. Undoubtedly, the news could have been imparted to Mrs V in a more compassionate and professional manner.
SPIKES is one well-established model of delivering bad news. Let us explore that model.
Create the appropriate setting for communicating with your patient. Advanced planning is important. Identify a quiet, comfortable room. Ensure that there will be no phones ringing, people entering the room or interruptions. Have some water and tissues available. While it should be an experienced, senior doctor leading out on the consultation, it can be helpful for a trainee, preferably someone the patient has met, to sit in on the consultation. It can be very helpful to have a nurse present or a person who could remain with the patient after your consultation has finished. In advance of the consultation the patient can be asked if they would like a friend or relative with them. By suggesting this you are sowing the seed that they may not get good news. There will be situations where a person attends a consultation alone and unexpected bad news is delivered. This can happen particularly in maternity services. In this situation it may be appropriate to pause the consultation to allow a friend or relative to join them. It is also important to identify if the patient needs a medical interpreter, sign language translator or other specific support. In advance it is crucial to familiarise yourself with the patient’s clinical notes and carefully consider how you will manage the meeting.
Prior to delivering the results or news it is important to explore what the person understands of their care to date, where appropriate. This gives you an opportunity to watch their body language and cues. You may be able to gauge their response to the news you are about to give.
Once again this highlights the importance of understanding the person’s ability to understand both medically, psychologically, and cognitively what they are about to hear. “What did you understand after your last visit to the clinic?” “What has you GP told you about your medical condition?”
They may have been transferred to your care from another team: “Did Doctor Y explain why you have been referred to my team?” It is not unusual for families to try to protect older relatives from hearing bad news. However, it is our responsibility to appreciate what the patient is able to deal with. Most importantly, avoid using medical terminology. Plain English is important to avoid misunderstandings.
Delivering bad news should be direct and honest. The gravitas of your body language is crucial. “I’m afraid I have difficult news for you today.” “I’m afraid I have bad news for you today.”
Pause and watch very carefully for their reaction. Allow the news to sink in. Always speak slowly, clearly, and make eye contact. You may have to repeat information if your patient is in shock. Ensure that they have understood the information given. Consider what positive news you can give.
Occasionally, people may be angry, in disbelief, crying or helpless. This is important for picking up on cues and validation.
We can never say: “I understand how you must feel” or “I know how you feel”. We can never know how they feel. We can, nevertheless state “this must be very difficult to take in” or “this must be a shock for you….”
One of the most challenging situations can be when your patient becomes angry on hearing bad news. This is a very normal reaction.
It does not mean the person will make a complaint about you and dealing with this situation takes experience. Remaining calm is important. Staying silent to allow them to express their feelings is very important.
It is important to acknowledge their emotions and provide time to allow them to express and explain their anger. This may take time and you may not have all of the answers for them there and then.
This is one situation where a follow-up consultation will allow you to meet them with some answers. It also provides an opportunity for a more experienced colleague to join you for that consultation.
In summarising the consultation, it is important to ensure that the person has understood as much of the information as possible.
Clinicians can acknowledge that there was a lot of information and that you will meet them for further consultation in the near future to further discuss their concerns and questions. They can be encouraged to write down any queries/questions they may have for that consultation.
If an experienced member of your team has been present throughout the conversation, they may be able to stay with the person to ensure their wellbeing prior to leaving the clinic.
In general, clinicians have always assumed that communicating bad news in person was more preferable than doing so over the phone. The COVID-19 pandemic created a necessity for telemedicine consultations and clinicians are becoming more comfortable with the modality.
Some situations such as sudden death or sudden deterioration of an inpatient may require a communication via telephone or video consultation.
Mueller et al reviewed the disclosure of bad news over the phone vs in person. They found no difference in levels of psychological distress if bad news was delivered by telemedicine or in person. Their findings suggest that the way in which the information was delivered might be more important than the modality of disclosure. The tone used is the most important factor followed by the words used.
Telemedicine requires experience and SPIKES principles outlined in this article still apply. Identify that you are speaking to the correct person. Should you ring later, unless of course it is an emergency?
Ensure that they are in an appropriate location with appropriate people present. Explain who you are and who is in attendance with you.
In the case of Mrs V using the SPIKES principles could have avoided a lot of distress and provided a more positive experience for this lady. Perhaps reflect on what would have been a more appropriate way to conduct that phone interaction.
A study by Brouwer et al highlights that parents experience barriers in bad news conversations. Their main concerns were practical aspects of communication skills.
The paper highlights:
A lack of timely communication, meaning that parents may not be explicitly told about their child’s future prognosis.
Failure to ask parents for an input.
Parents feeling unprepared during and after the conversation.
Physician’s failure to voice uncertainties. As doctors we often feel that we cannot acknowledge that we don’t know.
Parent’s lack of understanding of medical terminology.
Presence of too many, or unknown, healthcare professionals.
Parents concerns about breaking bad news to their child.
Failure to schedule follow-up conversations.
Many of the issues raised in this paper only reiterate SPIKES. However, the consultations in paediatrics are more complex. They are triangular relationships requiring many family members and a multidisciplinary team of healthcare professionals.
Whether you deliver bad news regularly or very rarely it is important to have ways of self-care. It is also normal for doctors to feel emotions such as guilt or anxiety. Self-care could be mindfulness, being involved in a Ballint Group.
Healthcare staff require, and want, training and reflection on the delivery of bad news.
Preparation prior to the consultation is pivotal.
Explore models such as SPIKES for support in delivering bad news.
Investigate the resources available within HSE, the Irish Hospice Foundation and Medical Protection e-learning for education on delivering bad news.
Make certain that self-care for yourself and your colleagues are available for ongoing wellbeing.
