1. Understanding “breaking bad news”
Clare Warnock
Practice development sister
WPH

2. What is breaking bad news
How would you describe breaking bad news
Who does it
What is bad news

3. What is breaking bad news
Traditional view
the moment when a doctor provides significant information about diagnosis, prognosis or treatment to patients and their families in a one to one consultation
the role of the HCP is to be present
as a witness to what has been said and
providing support once the consultation is over
“Modern view”
A wide range of HCPs are involved in BBN
Other information can be classified as bad news
BBN is a process
There may be multiple episodes of information provision
often “ad hoc” and not part of a pre-planned consultation
It also includes activities that take place before, during and after bad news is given

4. Popular definition
any bad, sad or significant information that negatively alters a person’s expectation or perception of their present or future (Fallowfield and Jenkins 2004)
Key items
ANY information
Individual expectation
Individual perception

5. What do you think could classify as bad news Examples
informing relatives of a patient’s deterioration or death,
advising a patient that they need to move into a residential home,
explaining the details of arduous treatment such as renal dialysis or chemotherapy,
providing daily updates to family members when a patient’s condition is not improving
explaining transitions in care for example from curative to palliative to end of life
failed discharge plans
Telling someone they can’t drive any more

6. What is bad news – it depends!
the same information could be interpreted as good, bad or neutral by different people
influenced by subjective factors
patient’s expectations, values, life experiences and social situation
the events leading up to and surrounding the moment that the information is given
How might different people react to being told they need to have surgery?

7. Breaking bad news as a process
BBN is not about a single consultation
Dewar’s early work in spinal injury unit
Initial moment
Followed by multiple episodes of potential bad news
Realising the implications of spinal injury over time
It also involves the activities that take place before, during and after bad news is given

8. What activities are carried out around bad news?
Assessing the needs of patients and relatives for further information; recognising their cues and prompts
Working with the patient and family to achieve consensus when there are issues about who should be informed
Identifying and prioritising the patient’s preferences for information
Liaising with the appropriate members of the healthcare team to initiate discussions where the need is identified or requested
Coaching and supporting patients and relatives who find it difficult to ask questions or talk to the doctors

9. Other activities around BBN
Helping patients ask questions when they appear to be confused or reluctant to do so
Supporting others who are providing the information to find alternative words or explanations if the patient appears not to understand or needs clarification
Communicating what has been said in the consultation to the rest of the healthcare team
Eliciting patient and relatives’ feelings about the information they have received
Listening to and acknowledging the emotional reactions of patients and relatives to bad news
Explaining and discussing the information received and its implications

10. Other activities around BBN?
Answering questions as they arise, identifying and clarifying misunderstanding and explaining complex medical terminology
Providing information about the next steps in the care pathway
Helping the patient and relatives make decisions about care
Helping patients and relatives address complex issues e.g. what is meant by DNAR, informed consent, advanced care directives
Supporting patients and relatives when they realise the implications of their situation or the information they have been given
Helping the family reach a consensus when there is disagreement between them about the plan of care
Acting as an intermediary between patients, relatives and the healthcare team

11. Why is BBN important? Patient preference – research consistently shows
Most patients want to be informed
variations in the depth and level of knowledge desired
 Other potential positive outcomes
building a sense of trust between patients and the healthcare team
enabling patients and relatives to make appropriate decisions and plans based on a realistic insight into their situation

12. What are the negative consequences of not providing patients with bad news?

13. Consequences of not BBN
Impact on treatment and decision making
Patients receiving burdensome, inappropriate and unnecessary treatment
False optimism and being unable to marry what is happening with the information received
Misunderstanding and confusion over the intention and aim of treatment
Denying patients the opportunity to participate in decision making
Unnecessary anxiety in worrying about the unknown

14. Impact on end of life care
Depriving patients and families of essential time before the patient’s condition deteriorates
Preventing the discussion of end of life preferences
Denying patients the opportunity to get their affairs in order
Impact if relatives informed and the patient isn’t
Feeling isolated and unable to communicate with each other
Unnecessary strain on family relationships
Families carrying the burden of deception

15. Poor job and role satisfaction
Impact on the healthcare team
Job stress and burnout
Poor job and role satisfaction
Disagreement and fractured relationships if not all agree with the information provided

16. Word of caution
Some patients prefer not to receive some or all of the facts as this is how they cope with their illness
Cultural differences
preferences and behaviours around information relating to particular diagnoses, such as cancer, prognosis and end of life decisions
in some cultures it can be common for the family to be given the information while the patient is shielded from the full facts.
Individual patient’s preferences for information should guide the content, timing and delivery of information

17. Does being honest destroy hope?
research reveals that providing honest information does not remove hope
honest information can support patients in their efforts to maintain hope
reduces fear of the unknown
enables patients to match their hopes with the reality of their experience
Is this a contradiction?

18. Reframing hopes and goals (Campbell 2010)
“When we worry about destroying hope we are generally referring to a very specific hope of getting better or living longer.
But hope is a complex, multi-dimensional and above all flexible construct...
One can shift from hoping for a cure...to hoping to go home from the hospital.
Such a shift in the things one hopes for requires a reframing of goals to meet the realities at hand...(a reality) that none of us would wish for”

19. Reframing hopes - examples
Hopes described by patients with a life-limiting illness include:
living longer than expected
good symptom management
getting the most out of the time that is left
making it to certain events or achieving certain goals
mending damaged relationships
spending special time with family and friends
This doesn’t mean people want to be in that situation (or that they won’t be sad/angry/upset)
It is a way of coping that can be used over time

20. Summary – what have we learnt about BBN?
Bad news includes many different types of information
Information is defined as “bad news” by individuals and cannot always be determined in advance
BBN is a process with multiple episodes of information provision
as people experience the implications of their situation and raise questions and concerns
It also includes the activities before, during and after the news is given
HCPs carry out a wide range of diverse roles in relation to BBN

21. Final notes
The way that bad, sad and significant information is given is important
The consequences are long-lasting
How it is done can influence
experiences and satisfaction with treatment
relationships with the healthcare team.
adherence and compliance with treatment
coping with the consequences of illness
Providing information in a way that helps the patient understand and cope with what they are told requires skills and knowledge
Guidelines and good practice advice have been developed to support staff
These will be explored in the next section of the study day