Breaking Bad News

One of the most important jobs of a physician is to be a clear communicator. And one of the toughest challenges for a communicator is to deliver bad news. Physicians frequently must break bad news to patients and their loved ones

According to one estimate, over the course of a career an oncologist will break bad news to patients about 20,000 times, from the first shocking facts of the diagnosis to the news that death is near.(4)

What is meant by bad news ?

 Bad news is any information that changes a person's view of the future in a negative way . It is often associated with a terminal illness such as cancer.(2)

However, bad news can come in many forms, for example :

·        the diagnosis of a chronic illness (e.g., diabetes mellitus),

·         disability, or loss of function (e.g., impotence);

·        a treatment plan that is burdensome, painful, or costly;

·         and even information that physicians may perceive as neutral or benign.

·        a pregnant woman’s ultrasound verifies a fetal demise

         ·        a middle-aged woman’s magnetic resonance imaging scan confirms the clinical  suspicion of multiple sclerosis,

         ·        an adolescent’s polydipsia and weight loss prove to be the onset of diabetes.

·        It might simply be a diagnosis that comes at an inopportune time, such as unstable angina requiring angioplasty during the week of a daughter’s wedding,

      ·        or it may be a diagnosis that is incompatible with one’s employment, such as a coarse tremor developing in a cardiovascular surgeon.    (2,7)

The old concepts regarding disclosure of bad news :

Withholding bad news from patients was commonly practiced until recently.

·        Hippocrates advised “concealing most things from the patient while you are attending to him. Give necessary orders with cheerfulness and serenity…revealing nothing of the patient’s future or present condition. For many patients…have taken a turn for the worse…by forecast of what is to come.”(7)

·        In 1847, the American Medical Association’s first code of medical ethics stated, “The life of a sick person can be shortened not only by the acts, but also by the words or the manner of a physician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have a tendency to discourage the patient and to depress his spirits.”(7)

·        A 1961 survey of 193 physicians revealed that 169 (88%) routinely withheld cancer diagnoses. Furthermore, they often used euphemisms such as "growth" to describe cancer. The policy was "to tell as little as possible in the most general terms consistent with maintaining cooperation and treatment." However, the same study found that most patients desired the truth regarding their diagnosis.(2)

The recent trend :

In recent decades, the paternalistic model of patient care has been replaced by one that emphasizes patient autonomy and full disclosure . Honest disclosure of diagnoses, prognoses, and treatment options allows patients to make informed healthcare decisions that are consistent with their goals and values . (2)

The importance of disclosure :

·          When physicians withhold bad news, they diminish patient autonomy. (2)

·        Furthermore, it serves little or no purpose to withhold bad news from a patient who eventually discerns the nature of his or her illness. (2)

·        Patients who discover that information has been withheld may no longer trust their physician . (2)

·        Most patients, if they have cancer, want to be told about it, and they want to know what the likely treatments are, the side effects of treatment and their prognosis. (3)

·        A review of studies on patient preferences regarding disclosure of a terminal diagnosis found that 50 to 90 percent of patients desired full disclosure. (7)

N.B. Only under rare circumstances is nondisclosure of bad news ethically permissible . (2)

A difficult task :

                      ·          Breaking bad news has always been difficult for most physicians, and phrases like "dropping the bomb" are usually used to describe the task . (2)

•  for too long, doctors and nurses have been expected to undertake these difficult tasks without the necessary training and support. Also "The general feeling has been that these are not teachable skills - that either you have it or you don't," said Dr. Anthony Back, an oncologist at the Fred Hutchinson Cancer Research Center in Seattle. (3,4)  
• yet it was proved that Without systematic training, the breaking of bad news and discussions of cancer prognosis are likely to fall short of existing guidelines and patients' needs and expectations. (3)

Wrong practices :

• Doctors break the bad news of a cancer diagnosis to patients in a predictable and routine way (diagnosis, the relevant evidence, the need for further investigations, the treatments being considered and the probable outcome) regardless of patients' individual information needs. Obvious verbal and non-verbal cues of distress were not acknowledged and patients' immediate concerns were not explored. (3)Therefore at the end of the consultation, patients were usually left with  important, but undisclosed, concerns and also felt that the information. given had been inadequate for their needs.

• In addition, doctors and nurses in these situations have been found to adopt behaviors designed to prevent further disclosure. These "blocking behaviors" include telling patients that any distress is normal, switching the subject to neutral topics, giving information and advice before patients' concerns have been identified, focusing only on physical aspects of the condition, and using leading, closed and multiple questions. (3) 

Barriers to effective communication of bad news include :

• Doctors and nurses avoid exploring patients' feelings and concerns because they fear that it will provoke too much emotion, which could be harmful to patients. They feel that their training has not equipped them with the necessary skills to explore these issues and respond appropriately. Feeling that they are not being supported emotionally and practically by colleagues and supervisors has also been linked to a greater use of these "blocking behaviors".(3)  

·        physician fears : the fear of being blamed by the patient, of knowing all of the answers sought by the patient, of inflicting pain on the patient, and even the physician's own fear of illness and death. (2)

·          many physicians have had little or no formal training in how to break bad news, (2)

·        and many perceive a lack of time in which to present the news. (2)  

·        Patients may have multiple physicians, making it unclear who should break the bad news. (2)

·          The hectic pace of clinical practice may force a physician to deliver bad news with little forewarning or when other responsibilities are competing for the physician’s attention. (7)

Robert Buckman's Six Step Protocol for Breaking Bad News :

• Dr. Robert Buckman, A specialist in breast cancer, he is a medical oncologist at the Toronto-Sunnybrook Regional Cancer Centre and an associate professor in the Department of Medicine at the University of Toronto. (5)
• "When I was an intern," Buckman says, "I would see doctors get so embarrassed when they had to give bad news to patients. I thought, 'There must be a protocol that will keep people from having to invent this conversation time and again.' "(5)
• Various authors make different recommendations about how this task should be accomplished. Some authors suggest making a more direct start to giving the news after a warning shot and gauging how to proceed as you go: they argue that patients who wish to use denial mechanisms will still be able to blank out what they do not want to hear. (1) 
• However, Buckman suggests a direct preliminary question such as “if this condition turns out to be something serious, are you the type of person who likes to know exactly what is going on?”. (1) 
• Robert Buckman, in an excellent short manual, has outlined a six step protocol for breaking bad news. The steps are: (6)

1. Getting started :

• The physical setting ought to be private, with both physician and patient comfortably seated.

• You should ask the patient who else ought to be present, and let the patient decide (studies show that different patients have widely varying views on what they would want).

• It is helpful to start with a question like, "How are you feeling right now?" to indicate to the patient that this conversation will be a two-way affair.

2. Finding out how much the patient knows :
By asking a question such as, "What have you already been told about your illness?" you can begin to understand :

•  what the patient has already been told ("I have lung cancer, and I need surgery"),
• or how much the patient understood about what's been said ("the doctor said something about a spot on my chest x-ray"),
• the patients level of technical sophistication ("I've got a T2N0 adenocarcinoma"),
•  and the patient's emotional state ("I've been so worried I might have cancer that I haven't slept for a week").

3.      Finding out how much the patient wants to know :

• It is useful to ask patients what level of detail you should cover. For instance, you can say, "Some patients want me to cover every medical detail, but other patients want only the big picture--what would you prefer now?" This establishes that there is no right answer, and that different patients have different styles. Also this question establishes that a patient may ask for something different during the next conversation.

4.      Sharing the information :

• Decide on the agenda before you sit down with the patient, so that you have the relevant information at hand.
• The topics to consider in planning an agenda are: diagnosis, treatment, prognosis, and support or coping. However, an appropriate agenda will usually focus on one or two topics.
• For a patient on a medicine service whose biopsy just showed lung cancer, the agenda might be: a) disclose diagnosis of lung cancer; b) discuss the process of workup and formulation of treatment options ("We will have the cancer doctors see you this afternoon to see whether other tests would be helpful to outline your treatment options").
• Give the information in small chunks, and be sure to stop between each chunk to ask the patient if he or she understands ("I'm going to stop for a minute to see if you have questions").
•  Long lectures are overwhelming and confusing.
•  Remember to translate medical terms into English, and don't try to teach pathophysiology.

5.       Responding to the patients feelings :

• If you don't understand the patient's reaction, you will leave a lot of unfinished business, and you will miss an opportunity to be a caring physician.
•  Learning to identify and acknowledge a patient's reaction is something that definitely improves with experience, if you're attentive, but you can also simply ask ("Could you tell me a bit about what you are feeling?").

6.      Planning and follow-through :

• At this point you need to synthesize the patient's concerns and the medical issues into a concrete plan that can be carried out in the patient's system of health care.
• Outline a step-by-step plan, explain it to the patient, and contract about the next step.
• Be explicit about your next contact with the patient ("I'll see you in clinic in 2 weeks") or the fact that you won't see the patient ("I'm going to be rotating off service, so you will see Dr. Back in clinic").
•  Give the patient a phone number or a way to contact the relevant medical caregiver if something arises before the next planned contact.

N.B. for more details : www.skillscascade.com/badnews.htm                              www.fastcompany.com/online/23/buckman.html

Other guidelines and protocols :

(A) Girgis and Sanson-Fisher guidelines on conveying information to patients about serious disease or death, include : (3)

• ensuring privacy
• allowing adequate time,
• assessing patients' understanding,
•  giving information about diagnosis and prognosis simply and honestly, avoiding euphemisms,
•  encouraging patients to express feelings,
•  being empathic,
• giving a broad but realistic time-frame concerning prognosis,
• arranging a review.

(B) Dr. Robert Arnold, an internist and communications expert at the University of Pittsburgh, suggested: (4)

·        "Name your emotions. And then acknowledge he doesn't have to have the same ones."

·        Find out who the patient is.

·        Be direct. "Say 'Help me understand your story,' or 'Are you the kind of person who likes to know all the details?"'

·        "Figure out what kind of doctor your patient wants you to be."

(C) SPIKES: A mnemonic for breaking bad news to patients by Baile and colleagues  

www.postgradmed.com/issues/2002/09_02/editorial_sep.htm

(D) The ABCDE Mnemonic for Breaking Bad News by Rabow and McPhee http://www.aafp.org/afp/20011215/1975.pdf

Other helpful phrases and questions are :

·        "I wish I had better news" (as opposed to "I'm sorry, I have bad news"),

·        "I admire your courage,"

·        "I will be here for you,"

·         "What gives you hope and strength?"

Unhelpful statements include :

·        "It could be worse,"

·         "We all die,"

·        "I understand how you feel,"

·           "Nothing more can be done."         (2)

What if the patient starts to cry while I am talking?

In general, it is better simply to wait for the person to stop crying. If it seems appropriate, you can acknowledge it ("Let's just take a break now until you're ready to start again") but do not assume you know the reason for the tears (you may want to explore the reasons now or later). Most patients are somewhat embarrassed if they begin to cry and will not continue for long. It is nice to offer kleenex if they are readily available (something to plan ahead); but try not to act as if tears are an emergency that must be stopped, and don't run out of the room--you want to show that you're willing to deal with anything that comes up. (6)

Finally it is obvious that acquiring the skill of breaking bad news greatly required because 'How a physician delivers bad news may affect patients' understanding of and adjustment to the news as well as their satisfaction with their physician'. (2)

 The limits of medicine assure that patients cannot always be cured. These are precisely the times that professionalism most acutely calls the physician to provide, hope and healing for the patient. (7)

References:

(1) www.skillscascade.com/badnews.htm

(2) www.postgradmed.com/issues/2002/09_02/editorial_sep.htm

(3) www.mja.com.au/public/issues/171_6_200999/maguire/maguire.html

(4) www.iht.com/articles/2006/01/11/healthscience/sncancer.php

(5) www.fastcompany.com/online/23/buckman.html

(6) http://depts.washington.edu/bioethx/topics/badnws.html

(7) http://www.aafp.org/afp/20011215/1975.pdf

                                               by Omnia Mohamed Mostafa (5th year) 

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