1. Breaking Bad News Dr.Arafat Aldujaili Ass.Professor Psychiatrist
Advanced Certified Autism Specialist
Ambassador and Fellow Of American Psychiatric Association
M.B.Ch.B, FICMS, ACAS, FAPA, IARCP.

2. Objectives
Be aware of situations where Drs may be called on to break bad news
Be aware of individual differences in perceptions of bad news among patients
Discuss the implications for patients and carers if bad news is not delivered considerately
Describe good practice for health professionals when breaking bad news

3. What is bad news?
Any information that drastically alters a patient’s view of their future for the worse (Kaye, 1996).
Situations where there is either a feeling of no hope, a threat to a person’s mental or physical well-being, a risk of upsetting an established life-style, or where a message is given which conveys to an individual fewer choices in his or her life (Buckman, 1984).

4. Some typical Breaking Bad News situations
Terminal prognosis
Disabling condition
Traumatic/sudden death
Infertility
Antenatal testing
Intra-uterine death

5. Is bad news always bad news?
Should not make assumptions that the news is entirely bad
patient may feel relief at finally having a diagnosis
able to be treated / out of pain
carer may feel burden lifted
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
Age.
Familial obligations.

6. Disclosure
It is important to inform the patient when the diagnosis is confirmed.
Move towards greater openness in the communication of information about life threatening illness.
In the UK 95% of GPs disclose cancer diagnosis (e.g. Vassilas & Donaldson 1998).

7. 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.
(Kaye, 1996)

8. Why is it important to tell patients when there is bad news?
Doctors find it easier to treat and care for patients if they know their diagnosis (Seale, 1991).
Lack of information can increase patient uncertainty, anxiety, distress, & dissatisfaction (Audit Commission, 1993)
Most patients wish to know their diagnosis, and be informed about the progress of the treatment and disease.
e.g. 96% cancer patients wanted to know diagnosis; 91% wanted to know chances of a cure
79% wanted as much information as possible (Meredith et al 1996)

9. Individual differences
Some patients, especially those with a poor prognosis may not want all the details
Patient and relatives may differ in their need to know (Maguire, 1996).
Need to avoid collusion

10. Avoiding collusion Collusion – why?
Desire to protect relative
Protect self from discussing difficult issues with patient
Truth may take away patient’s hope?
But 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

11. Cultural differences
In the UK, Northern Europe, North America, Australia almost all cancer patients are told the truth.
exceptions: young children, cognitive impairment.
The open approach is not practised in all cultures - Southern & Eastern Europe and parts of Asia.
In some cultures illness is viewed as shameful, it is deemed cruel to tell patient, or it is considered dangerous to talk about prognosis and to name the illness. (e.g. Littlewood & Elias 2000; Mathews et al 1994)

12. It is not easy to break bad news

13. 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.
(Kaye, 1996)

14. Why is it important that the BBN interview is performed adequately?
Doctor-patient relationship
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. (Kruijver et al, 2000)
If bad news is not delivered well this can have an impact on
emotional well-being e.g. distress and depression (Kings Fund, 1996, Mager & Andrykowski 2002)
adjustment to and ability to cope with the illness, for patients and their relatives (Woolley et al 1989; Fallowfield 1993)

15. How to Break Bad News
No universally agreed guidelines on how to break bad news, although there is a general consensus (Ptacek, 1996)
Most patients expect full disclosure delivered with empathy, kindness & clarity (Buckman 2005)
Key guidelines:
10-step approach (Kaye)
S-P-I-K-E-S (Buckman)
Consensus guidelines (Girgis & Sanson-Fisher)

16. Key points: 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.

17. Key points: What does the patient know?
Assess patient understanding:
Use facilitating behaviours:
Listen to language used by patients:

18. Key points: Breaking the news
Use a warning shot:
Direct patient to diagnosis:

19. Key points: Responding to patient needs
Explore how much information patient requires:
Be optimistic/positive
Listen to patient’s concerns, allow emotional response “

20. Key points: Concluding the consultation
Strategy:
Discuss strategy, agree on a clear plan.
Summary:
Summarise the main discussion topics.
Closure:
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.

21. Model for Breaking Bad News

22. Documenting the Consultation
Patients 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

23. Summary
There are various definitions of ‘bad news’. More likely to occur in some areas of medicine, but ‘bad ’ is subjective so can occur in any area.
Patients perceptions & needs may differ due to individual characteristics, age, sex, culture etc.
Breaking bad news badly can damage doctor-patient relationship, patient well-being and ability of patient and relatives to cope
Doctors need to apply good practice guidelines, but remember to treat patients as individuals