1. Brig Khalid Hayat Khan Classified Psychiatrist AFIMH Rawalpindi
Breaking The Bad News
Brig
Khalid Hayat Khan
Classified Psychiatrist
AFIMH Rawalpindi

2. Breaking the Bad News
There are many real life situations where bad news has to be communicated to the patient, their relatives and/or even to those you even don’t know. For e.g.
Disclosing the diagnosis of incurable or dreadful diseases like cancers, AIDS, ischaemic heart disease etc.
Disclosing still birth of the baby to mother.
Disclosing death of a loved one.
Disclosing massive financial loss, property loss.

3. Breaking the Bad News
Breaking the bad news is an unpleasant task and can be learned from the senior physicians or through own professional experience.
There are five schools of thought regarding breaking the bad news.
The biopsychosocial (BPS) model
Individualized disclosure model
Full disclosure model
Paternalistic disclosure model
Non disclosure model

4. BPS Model
It provides a clear, crisp, evidence based information on the patient’s condition but tailors the flow and amount of information according to the needs of the patient.
A vertical flow of all data on the disease is avoided. The bad news is broken using the principles of effective communication, counseling and informational care. The patient is encouraged to involve his family members, as a part of psychosocial support, during the session as well as in the long run.

5. Step 1: Seating and Setting (Environment)
BPS Model
It is the best model to be recommended for use in health settings.
This model suggests the following steps for a session that aims at breaking a bad news:
Step 1: Seating and Setting (Environment)
Exclusivity: A private room where doctor and patient can focus on the subject attentively.

6. BPS Model
Involvement of significant others: This gives patient psychosocial support and alleviates some stress from the doctor in the face of an emotionally charged interview.
Seating arrangements: The doctor and the patient should be comfortably and respectfully seated next to each other, preferably at a distance of an arms length
Be attentive and calm; maintain eye contact:
Care about patient’s feelings if he weeps during the interview:

7. Step 2: Patient’s perception
BPS Model
Listening mode: Silence and repetition of last few words that the patient has said, are two communication skills that will send across the message that you are listening well.
Step 2: Patient’s perception
Before breaking bad news, try to ascertain as accurately as possible, the patient’s perception of his or her medical condition. If the patient is in

8. BPS Model
denial, try not to confront him in the first interview, as denial is an unconscious defense mechanism that facilitates coping.
Step 3: Invitation
Although most patients want to know all about their illness but assumption towards that should be avoided. Obtaining overt permission respects the patient’s right to know or not to know.

9. BPS Model Some examples to address this are:
“Are you the kind of person who likes to know all the details about what’s going on?”
“How much information would you like me to give you about your diagnosis and treatment?”
“ Would you like me to give your details about what is going on or would you prefer to know about the treatments I am prescribing to you?”

10. BPS Model Step 4: Knowledge
Before breaking the bad news, give your patient a warning of some sort to help him prepare for himself e.g.
“Unfortunately I have some bad news to tell you Mr . X……….”
“ I am sorry to tell you Mr. X that………”
“ Mr. X every human being in this world faces ups and downs in his or her life, do you

11. BPS Model agree with it ?…………”
“The life is such that every one of us has to come across some bad event/news which one has to bear with courage……….”
“ Mr. X how are you going to respond to the scenario of a person, that I am going to put in front of you, who has suddenly lost one of his son in earthquake disaster……….”

12. BPS Model Step 5: Empathy
Show empathic response to the patient. In empathic response one needs to listen and identify the emotion (or mixture of emotions) that the patient is experiencing and acknowledge them. Validate patient’s feelings, reassure him that you understand the human side of the medical issue and that you have a respect for his feelings.

13. BPS Model Step 6: Summarize
Before the discussion ends, recapitulate the information in a short summary of all that has been discussed and give your patient an opportunity to voice any major concerns or questions.

14. BPS Model Step 7: Plan of Action
You and your patient should go away from the interview with a clear plan for the next steps that need to be taken and the role you both would play, in the management of the issues.

15. Individualized Disclosure Model
The amount of information disclosed and the rate of its disclosure are tailored to the individual patient by doctor-patient negotiation.
The underlying assumptions in this model are that people are different, it takes time to absorb and adjust to bad news and a partnership between doctor and the patient for decision making is in the patient’s best interest.
The distinguishing feature of this model are that it takes time and skills which the busy physician

16. Individualized Disclosure Model
may feel that he or she does not have.
The advantages are that the amount of information given and rate of disclosure is tailored to the needs of individual and a supportive relationship with the doctor is established.
The disadvantages are that it is a very time consuming process, requires skills and it drains a caregiver’s emotional resources.

17. Full Disclosure Model
This model involves giving full information to the patient with the underlying assumptions that the patient has a right to full information about himself and the doctor has an obligation to give it; patient himself should decide what treatment is best for him.
The advantages are that it promotes doctor-patient trust and communication; and facilitates mutual support within the family unit.

18. Full Disclosure Model
The disadvantages are that the discussion of options in detail may frighten and confuse some patients; insisting on information may undermine defenses e.g. denial, which are otherwise important for the survival of the patient; and lastly full information may have negative emotional consequences for some.

19. Paternalistic Disclosure Model
This model implies that the information about patient’s disease is the right of the doctor and he delivers the information in a “sugar coating” to minimize the pain and distress of the patient.
It also involves the expression of sympathy and a sharing of emotions on the part of the doctor.
This model is not a recommended method any more.

20. Non Disclosure Model
This model is based on the view that under no circumstances should patients be informed that they have acquired a lethal disease, and that deception should be used if necessary, on the basis that the patient needs protection from the terrible reality of terminal illness.
The advantages of this model are that it is easier, less time consuming for the doctor and suits those people who prefer not to know their condition.

21. Non Disclosure Model
The disadvantages are that the trust in doctor is undermined; opportunities for helpful interventions are lost; patient’s compliance is less likely; patient may acquire wrong information from anybody that can lead to avoidance, isolation and a perceived sense of rejection.
This model is out of favour and is widely rejected by modern day doctors as well as patients and their families.

22. THANK YOU