Breaking Bad News

Article: Breaking Bad News

Tony Back, MD (2013)

Breaking bad news is not something that most medical students are eager to try. Dilbert's advisor Dogbert says: "Never break bad news...it will only get you in trouble." And stories abound about how unskilled physicians blundered their way through an important conversation, sometimes resulting in serious harm to the patient. Many patients with cancer, for example, can recall in detail how their diagnosis was disclosed, even if they remember little of the conversation that followed, and they report that physician competence in these situations is critical to establishing trust.

Some physicians contend that breaking bad news is an innate skill, like perfect pitch, that cannot be acquired otherwise. This is incorrect. Physicians who are good at discussing bad news with their patients usually report that breaking bad news is a skill that they have worked hard to learn. Furthermore, studies of physician education demonstrate that communication skills can be learned, and have effects that persist long after the training is finished.

Robert Buckman's Six Step Protocol for Breaking Bad News Robert Buckman, in an excellent short manual, has outlined a six step protocol for breaking bad news. The steps are:

  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 patient's 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.

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 tissues 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.

I had a long talk with the patient yesterday, and today the nurse took me aside to say that the patient doesn't understand what's going on! What's the problem?

Sometimes patients ask the same question of different caregivers, sometimes they just didn't remember it all, and sometimes they need to go over something more than once because of their emotional distress, the technical nature of the medical interventions involved, or their concerns were not recognized and addressed.

I just saw another caregiver tell something to my patient in a really insensitive way. What should I do?

First, examine what happened and ask yourself why the encounter went badly. If you see the patient later, you might consider acknowledging it to the patient in a way that doesn't slander the insensitive caregiver ("I thought you looked upset when we were talking earlier and I just thought I should follow up on that--was something bothering you?")

Additional Readings | Related Websites

 

Related Topics:

Mistakes 

Truth-telling and Withholding Information   

 

Core Clerkships: 

Internal Medicine

Surgery 

Urology

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  • Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-11.
  • Campbell TC, Carey EC, Jackson VA, Saraiya B, Yang HB, Back, AL, Arnold RM. Discussing prognosis: Balancing hope and realism. Cancer Journal. 2010;16(5):461-466.
  • Fujimori M, Akechi T, Morita T, Inagaki M, Akizuki N, Sakano Y, Uchitomi Y. Preferences of cancer patients regarding the disclosure of bad news. Psycho-Oncology. 2007;16(6):573-581.
  • Martins RG, Carvalho IP. Breaking bad news: Patients’ preferences and health locus of control. Patient Education and Counseling. 2013;92(1):67-73.
  • Von Gunten CF, Ferris FD, Emanuel LL. The patient-physician relationship. Ensuring competency in end-of-life care: communication and relational skills. Journal of the American Medical Association. 2000 Dec 20;284(23):3051-7.
 
 
 

CASE STUDIES

Case 1: Jose is a 62-year-old man who just had a needle biopsy of the pancreas showing adenocarcinoma. You run into his brother in the hall, and he begs you not to tell Jose because the knowledge would kill him even faster. A family conference to discuss the prognosis is already scheduled for later that afternoon.

How should you handle this?

Case Discussion

It is common for family members to want to protect their loved ones from bad news, but this is not always what the patient himself would want. It would be reasonable to tell Jose's brother that withholding information can be very bad because it creates a climate of dishonesty between the patient and family and medical caregivers; also, that the only way for Jose to have a voice in the decision making is for him to understand the medical situation. Ask Jose how he wants to handle the information in front of the rest of the family, and allow for some family discussion time for this matter.

In some cultures it is considered dangerous to talk about prognoses and to name illnesses (e.g., the Navajo). If you suspect a cultural issue it is better to find someone who knows how to handle the issue in a culturally sensitive way than to assume that you should simply refrain from providing medical information. For many invasive medical interventions which require a patient to critically weigh burdens and benefits, a patient will need to have some direct knowledge of their disease in Western terms in order to consider treatment options.

You are a 25-year-old female medical student doing a rotation in an HIV clinic. Sara is a 30-year-old woman with advanced HIV who dropped out of college after she found that she contracted HIV from her husband, who has hemophilia. In talking to Sara, it turns out you share a number of things--you are from the same part of Montana originally, also have young children, and like to cook. Later in the visit, when you suggest that she will need some blood tests, she gets very angry and says, "What would you know about this?"

What happened?

Case Discussion

Although the protocol for breaking bad news is helpful, it doesn't cover everything. There are instances when you may provoke a reaction from a patient because you remind them of someone else--or, as in this case, themselves. In these instances it can be helpful to step back, get another perspective (perhaps from someone in clinic who has known Sara), and try not to take this reaction too personally--even though it is likely that Sara will know how to really bother you.