1. Breaking Bad News Dr. Riaz Qureshi
Distinguished Professor Family Medicine
Dept. of Family & Community Medicine
King Saud University ,Riyadh, Saudi Arabia

2. Breaking Bad News Learning Objectives for Students/Trainees:
To understand why this is an important part of communication skills.
To understand the definition of bad news.
The students/trainees should become aware of:
What to do?
How to do it?
What not to do?
Students/Trainees should also become familiar with certain illnesses/ problems which may require giving bad news.

3. Breaking Bad News
A difficult but fundamentally important task for all health care professionals
Physicians feel uncertain & uncomfortable while breaking bad news, leading to being distant & disengaged from their patients.

4. Breaking Bad News Recent studies have shown that:
Patients generally (50-90%) desire full & frank disclosure, though a sizeable minority still may not want the full disclosure. (Ley p. Giving information to patients. New York: Wiley, 1982 )
Focused training in communication skills & techniques to facilitate breaking of bad news has been demonstrated to improve patients satisfaction & physicians comfort.

5. What is bad news?
“any news that drastically and negatively alters the patients view towards his future.”
Buckman R. BMJ1984
It alters one’s self-image : “I left my house as one person & came home another.”
Professional cyclist Lance Armstrong’s recollection

6. Examples reported by clinical consultants
Examples of Conditions Requiring Breaking of Bad News
Cancer related diagnoses
Intra uterine foetal demise
Life long illness: Diabetes, Epilepsy
Poor prognosis related to chronic diseases: loss of independence
Informing parents about their child’s serious mental/physical handicap
Giving diagnosis of serious sexually transmitted disease …catastrophic psychosocial results
Non clinical situations like giving feedback to poorly performing trainees or colleagues

7. Psychosocial Context
Patients response is influenced by previous experiences & current social circumstances---inappropriate timing
Even simple diagnosis being incompatible with one’s profession---tremors in cardiac surgeon.
Varying needs of patient & family---patient wishes to know more himself & less information to pass on to family, family wishes vice versa.

8. Barriers to effective disclosure
It is referred by some physicians like “dropping the bomb”
Baile W F, oncologist 2000
Common Barriers include
Physician’s fears of :
Being blamed by patient
Not knowing all the answers
Inflicting pain & sufferings
Own illness & death
Lack of training
Lack of time
Multiple physicians---who should perform the task

9. Patient’s perspective
Most important factors for patients include:
Physician’s competence, honesty & attention
The time allowed for questions
Straightforward & understandable diagnosis
The use of clear language
Parker PA, Baile WF j.clinical onc 2001

10. Family's perspective Family members prefer: privacy
Good attitude of the person who gives the bad news
Clarity of message
Competency of physicians
Time for questions
Jurkovich GJ, et al. J Trauma 200

11. Delivering Bad News
“It is not an isolated skill but a particular form of communication.”
Frank A. Eur J of Palliat care 1997
Rabow & Mcphee (West J. Med 1999) described: “Clinicians focus often on relieving patients’ bodily pain, less often on their emotional distress & seldom on their suffering.”

12. Delivering Bad News
Rabow & Mcphee (West J. Med 1999) synthesized a simple mnemonic of ABCDE:
Advance Preparation
Build a therapeutic environment/relationship
Communicate well
Deal with patient & family reactions
Encourage and validate emotions

13. Advance Preparation
Familiarize yourself with the relevant clinical information (investigations, hospital report)
Arrange for adequate time in private, comfortable environment
Instruct staff not to interrupt
Be prepared to provide at least basic information about prognosis and treatment options (so do read it up)

14. Advance Preparation
Mentally rehearse how you will deliver the news. You may wish to practice out loud
Script specific words & phrases to use or to avoid
Be prepared emotionally

15. Build a therapeutic environment/relationship
Introduce yourself to everyone present
Summarise where things have got to date, check with patient/relative
Discover what has happened since last seen
Judge how the patient is feeling/thinking
Determine the patient’s preferences for what and how much he/she wants to know

16. Build a therapeutic environment/relationship (contd)
Warning shot “I’m afraid it looks more serious than we had hoped”
Use touch where appropriate
Pay attention to verbal & non verbal cues
Avoid inappropriate humour
Assure patient that you will be available

17. Communicate well Speak frankly but compassionately
Avoid medical jargon
Allow silence & tears; proceed at patient’s pace
Have the patient describe his/her understanding of the information given
Encourage questions
Write things down & provide written information
Conclude each visit with a summary & follow up plan

18. Deal with patient and family reactions
Assess & respond to emotional reactions
Be aware of cognitive coping (denial, blame, guilt, disbelief, acceptance, intellectualization)
Allow for “shut down”, when patient turns off & stops listening
Be empathetic; it is appropriate to say “I’m sorry or I don’t know. Crying may be appropriate
Don’t argue or criticize colleagues

19. Encourage and validate emotions
Offer realistic hope
Give adequate information to facilitate decision making
Explore what the news means to the patient & inquire about spiritual needs
Inquire about the support systems in place

20. Encourage and validate emotions
Attend to your own needs during and following the delivery of bad news (counter-transference can be harmful)
Use multidisciplinary services to enhance patient care ( hospice)
Formal or informal debriefing session with concerned team members may be appropriate

21. What to do? Introduce yourself Look to comfort and privacy
Determine what the patient already knows
Warn the patient that bad news is coming
Break the Bad News
Identify the patient’s main concern
Summarize and check understanding
Offer realistic hope
Arrange follow up and make sure that some one is with the patient when he leaves

22. How to do it ? Be sensitive
Be empathic and consider appropriate touching
Maintain eye contact
Give information in small chunks
Repeat and clarify
Regularly check understanding
Do not be afraid of silence or tears
Explore patient’s emotions and give him time to respond
Be honest if you are unsure about something

23. What not to do ? Hurry Give all the information in one go
Give too much information
Use medical jargon or unclear language/words
Lie or be economical with the truth
Be blunt. Words can be like loaded pistols/guns
Guess the prognosis (She has got 6 months, may be 7)

24. Quotation
The greatest revolution of our generation is the discovery that human beings, by changing the inner attitudes of their minds , can change the outer aspects of their lives.
William James
American Psychologist & Philosopher

25. Angry Patient WHAT TO DO? Introduce yourself
Acknowledge the person’s anger
Try to find out the reason for his anger, e.g. frustration, fear or guilt
Validate his feelings
Let him ventilate his anger or any feelings that led to his anger
Offer to do something or for him to do something

26. Angry Patient HOW TO DO IT?
Sit at the same level as the patient, not too close and not too far, with eye contact
Speak calmly without raising your voice
Avoid dismissive or threatening body language
Encourage the person to speak with open ended questions
Empathize as much as you can with verbal and non verbal cues
Be aware of your own safety

27. Angry patient WHAT NOT TO DO? Glare at the person
Confront him or interrupt him
Patronize him or touch him
Put the blame on others/seek to exonerate yourself
Make unreasonable promises
Block his exit
If the person is a patient’s relative, be mindful about confidentiality

28. SCENARIO Tariq, a 55-year-old chain smoker taxi driver with persistent cough for 3 months, attends your clinic to find out the biopsy report of a lesion shown on a chest x-ray and CT scan. He is rather anxious, that he has a serious condition. His biopsy report confirms that he has a Bronchogenic Carcinoma of right lung. You are required to proceed with this consultation.

29. Scenario No 2 Proceed with this consultation.
A 54-year-old lady attends your clinic to find out the result of an MRI of her spine. She has had constant pain all over her spine for the last 2 months. She also has a history of Breast cancer, which was treated 5 years ago.
Her report shows that she has secondaries all over her spine
Proceed with this consultation.
(Examination not required)