Breaking

Bad

News

Delivering or breaking bad or unfavourable news is a common problem in medical practice but up to date
not taught often enough. It should be very much patient centred rather than determined by the doctor, e.g. a
cut finger can be disastrous news for a violinist but generally would be considered to be a minor injury.
Some patients even feel that being told to undergo an investigation like colonoscopy etc. means bad
news. Different things to different people!. .Bad news is in the eye of the beholder!
It is a difficult task and must be done well but cant and shouldnt be avoided! It is part of the Australian
culture to be direct and open and to tell the truth (open disclosure, AUTONOMY!).

Key Points:
Good Communication:
Sensitivity, choice of adequate, simple language. Use short sentences! Do not rush, be honest,
maintain HOPE without being unrealistic and demonstrate empathy!!!
Personally (requires experienced person) contact relatives, which can be very difficult on the
telephone!
Dont let people drive.
!!!Poor communication is responsible for more problems / complaints in the ED than poor
medicine!!!
Introduce yourself with name and role, make sure you have the right patient or
relative by asking their name or how you may address them (e.g. first name?).

Preparation:
Prepare yourself for the task. Be clear about what you want to say, and how you will phrase the
news. Be sure about the facts and about consistency of information
provided. All staff should be clear in their understanding of events before breaking bad news. Have
the same story!
Prepare yourself emotionally for the encounter you need to sort out your own feelings about the
event. Do you feel guilt? Are you at risk of blaming the patient for the adverse outcome? Give
yourself a bit of space before sitting down to talk.
Keep information simple and avoid technical jargon.
Assess the recipients understanding and perception (gathering information from the patient)
of the situation and what the bad news might be before you start, e.g.
Whats your understanding ..why we did the CT? ..or.of what has been happening?
What have you been told about.. so far?
You know the reason for this meeting?.
Can you tell me what you know?
Did you think something serious was going on?
This would reinforce that they have accurate information about the situation and where things
might be going.
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This approach is captured by the word SIT:

S for SIT DOWN which is saying to the patient Im here to spend time with you, Im not going
away, Im not going to leave you quickly!
I stands for INTRODUCE which means putting yourself into context if e.g. you are not the
regular attending doctor.
T stands for TELL rather than conveying a message I dont want to be here! For example It is
always worrying, waiting for the results of tests, so I understand that you are anxious about it. I am
happy to tell you as much as you would like to know about this procedure, and what the results are.
Now would you like me to explain it in full detail, or would you just like the main bits?
(Options ranging from non-disclosure to partial or individualized disclosure to full disclosure)
I am afraid I have bad news.
I am sad to have to tell you that..
Arrange adequate time and privacy.
Offer to arrange for a friend or relative to be present because sometimes patients like to have a
trusted person present for support other times they want to be alone that needs to be clarified and
offered!

Place:
Choose a private place where you will not be interrupted, ideally a quiet room away from hectic
activity, ideally with coffee/tea making facilities or cold drinks (auditory and visual privacy!!!).
Always provide a box of tissues. Make sure it is an undisturbed meeting (phone and pager off!!!).
Gather all people who are significant to the situation, although you have to identify the patients
preferences regarding the disclosure of bad news.

Consider provision of a body viewing or quiet room for relatives to touch the body (if
requested) and to say good bye.
Be Direct: (provide intelligible information in accordance with the patient's needs and
desires)
Lead up to the bad news, e.g. I am sorry, but the news is not good, it is cancer!.. Or Now I am
very sorry to tell you this news but the tests showed that you do have a type of cancer. This is
clearly a shock for you. I am sorry I am unable to give you better news.
Things are not going as well as yesterday.
We will continue to do everything we can
Use simple language, avoid euphemisms and medical jargon (e.g. metastasis vs spread of cancer),
speak in short sentences, so they can sink in. Dont beat around the bush. Identify the single most
important message! Get to the point quickly, although give information in an unhurried manor.
Explain reasons, be honest and direct, balanced with an empathetic manor. NEVER LIE (patients
want to know the truth)!!! Maintain HOPE!!!
Look, I understand that this is terrible news for you. But this type of cancer can be treated. If you
like, Ill come back in half an hour or so and well go throught the treatment options.
You have cancer! (full stop) vs. You have cancer and this is what we can do about it!

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Relatives should be given a clear explanation of the cause of death and/or the need of an autopsy
(surgery after the death to establish the exact cause of death).
Proceed at the patients pace are they keeping up with what you are saying? Keep information
simple and avoid medical jargon!
Allow time for questions!
Allow time for silence and tears and time to react and for facts to sink in and give opportunities to
ask questions.
Express empathy (ability to understand patients feelings): I know this must be a terrible shock to
you! or I am really sorry!
Do not overstep your knowledge base! (In the ED the full context of the patient and a newly
diagnosed condition is rarely known!). Look at the person youre talking to (eye contact). Be aware
of language barriers and cultural differences!
Having dropped what may well be a bombshell, wait for a reaction!
Ask the patient / relative what they would like to know, how far to go with explanations and
perhaps offer a second session rather than to try to cover every aspect in one sitting, because often
the patient does not take everything on board and cant make decisions at that time.
It is acceptable in the Australian society to comfort a relative by putting a hand or arm around the
shoulder or holding a persons hand in sympathy, but be aware of cultural differences (never touch
above the knee!).

Responses:
Now quietly observe and listen. Offer time and allow the facts to sink in!
Explore and respect expressions of feelings by recipients of the news. Dont minimize their
response.
Allow for shut down.
Invite people to describe their emotions, e.g. How do you feel about that? or Is this what you
were expecting?, This must be really hard for you?, You shouldnt feel guilty!.
Be prepared to be bombarded with question. Give as much information as the person is asking for,
without swamping them! The doctor should speak less than the patient and focuses on the patients
feelings!
You have to realise that the patient might not recall a lot of what you say in such a situation. Most
people are easily overwhelmed by bad news and will not be able to take in much more information
at that stage!
You can use strategies to increase patients recall:
1.
2.
3.
4.
5.

repeat important information, even 2x or 3x

stress significant material
use physical (pointing to an area on the body) and written prompts
summarise
ask patient to reflect understanding

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Effective listening communicates respect, caring and empathy.

If they are unnecessarily pessimistic, play up any positive aspects. Sad news should be
accompanied by positive support, understanding and encouragement!
However, if they seem unrealistically cheerful in an obviously bleak situation, probe to check that
you have been understood correctly. Avoid false reassurance!
Remember that people appreciate the truth and genuine support!
Be prepared for a wide range of responses (Kuebler-Ross!):
stunned
silence
shock
acute distress
denial, disbelief
I dont believe it
anxiety + anger
extreme guilt
sadness
helplessness
despair
why me?
guilt
could we have prevented this?
bargaining
adaptation and acceptance

Give permission and encouragement for reactions such as crying and screaming. Have a tissue box
available.
I can see this is very distressing for you
Clearly you are very angry about this
It must have been a frightening experience for you!
Can you bear to tell me how you feel about this?
EMPATHY: capacity to recognize and to share emotions that are being experienced by another
person
It must have been a frightening experience for you
SYMPATHY: is a concern for the well-being of another
I am very sad for you in the loss of your husband.
I wish - statements.
Elicit and prioritise all concerns:
Have you any particular concerns?
Can you tell me any of your thoughts or worries?
Is there anything else that is troubling you about the situation?
Do you feel I have covered all your concerns?
Offer a cup of tea or a cool drink, a glass of water and/or tissues.
.
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Closing the consultation:

Before we finish up, I would like to check if you have any questions or issues or anything else we
should discuss now. However, well have more time tomorrow to talk again. If you have any
questions or concerns, please feel free to give me or Dr. .. a call, here are the telephone
numbers. If the message bank is on, please leave your name and I will return the call asap.
would you like to talk to anybody else now?
Offer to talk to other members of the family and give information about support services.

Looking Ahead:
Present treatment options (incl. side effects, the option of no treatment), ideally in a second
consultation within 24 hours with a trusted person present who can independently hear the
information and a shared, clearly understood view is created and it avoids misunderstandings. Elicit
the patients collaboration in developing a strategy or treatment plan for the future!
Encourage the patient to write a list of all the significant questions they have so they can be
discussed.
Avoid giving a definite prognosis because that is often difficult to determine, stress the importance
of managing the problem and concentrate on issues which usually arise like pain management or
other factors of the disease which impact on the patients life.
Give information about and involve other services and support available, e.g. pastoral care, social
work, undertaker and who to notify (?next of kin).
Take the opportunity to ask questions like Who are you going home to now and what are you
going to say to them?. This gives you an opportunity to assess their understanding of the situation
(rehearsal) and you can check the accuracy of it.
It also allows an end of the discussion and closure for the time being.
However, dont forget to offer a follow-up discussion. Often people dont remember important
details and need further clarification. Ideally the same person should be available for such followup.
Summarise the content of conversation to ensure clear understanding, e.g. I would like to
summarise.., I know it is a big stress and a lot to take in but I just want to make sure you fully
understand and remember., You know what I mean .123.. These are the three
things.

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Debrief:
Discuss with appropriate person (?peer) after the event express your own feelings and thoughts
and reactions. Make sure that all staff members involved have an opportunity to debrief. You
MUST look after yourself and your colleagues to avoid burnout and depression.
Provide a break after a stressful event.
Look at yourself and your actions in a balanced way. Doctors often magnify their perceived errors
(and those of others!) without acknowledging what was done well.
Learn some stress management techniques. !Prevention, e.g. anticipate nightmares, waking up,
restless sleep, self accusations etc.

Breaking bad news is a very complex issue but can be dealt with very effectively by breaking the process
into segments:
OPENING THE CONSULTATION
EXPLORING THE PATIENTS PERCEPTIONS
BREAKING THE BAD NEWS
ALLOWING THE PATIENT TO EXPRESS THEIR FEELINGS
CONSIDERING TREATMENT OPTIONS
SUMMARISING
CLOSING THE CONSULTATION

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The Kbler-Ross grief cycle:

For many years, people with terminal illnesses were an embarrassment for doctors. Someone who could
not be cured was evidence of the doctors' fallibility, and as a result the doctors regularly shunned the
dying with the excuse that there was nothing more that could be done (and that there was plenty of other
demand on the doctors' time).
Elizabeth Kbler-Ross was a doctor in Switzerland who railed against this unkindness and spent a lot of
time with dying people, both comforting and studying them. She wrote a book, called 'On Death and
Dying' which included a cycle of emotional states that is often referred to (but not exclusively called) the
Grief Cycle.
In the ensuing years, it was noticed that this emotional cycle was not exclusive just to the terminally ill,
but also other people who were affected by bad news, such as losing their jobs or otherwise being
negatively affected by change. The important factor is not that the change is good or bad, but that they
perceive it as a significantly negative event.
The Grief Cycle can be shown as in the chart below, indicating the roller-coaster ride of activity and
passivity as the person wriggles and turns in their desperate efforts to avoid the change.

The initial state before the cycle is received is stable, at least in terms of the subsequent reaction on
hearing the bad news. Compared with the ups and downs to come, even if there is some variation, this is
indeed a stable state.
And then, into the calm of this relative paradise, a bombshell bursts...
Shock stage: Initial paralysis at hearing the bad news.
Denial stage: Trying to avoid the inevitable.
Anger stage: Frustrated outpouring of bottled-up emotion.
Bargaining stage: Seeking in vain for a way out.
Depression stage: Final realization of the inevitable.
Testing stage: Seeking realistic solutions.
Acceptance stage: Finally finding the way forward.
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Sticking and cycling

Getting stuck
A common problem with the above cycle is that people get stuck in one phase. Thus a person may
become stuck in denial, never moving on from the position of not accepting the inevitable future. When it
happens, they still keep on denying it, such as the person who has lost their job still going into the city
only to sit on a park bench all day.
Getting stuck in denial is common in 'cool' cultures (such as in Britain, particularly Southern England)
where expressing anger is not acceptable. The person may feel that anger, but may then repress it, bottling
it up inside.
Likewise, a person may be stuck in permanent anger (which is itself a form of flight from reality) or
repeated bargaining. It is more difficult to get stuck in active states than in passivity, and getting stuck in
depression is perhaps a more common ailment.
Going in cycles
Another trap is that when a person moves on to the next phase, they have not completed an earlier phase
and so move backwards in cyclic loops that repeat previous emotion and actions. Thus, for example, a
person that finds bargaining not to be working, may go back into anger or denial.
Cycling is itself a form of avoidance of the inevitable, and going backwards in time may seem to be a way
of extending the time before the perceived bad thing happens.

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THE SPIKES APPROACH (SIX STEP PROGRAM):

1. Setting up the interview in an appropriate setting:
PREPARATION, patient details,
provide privacy, including water and tissues etc.
involve significant others
Sit down, allow for eye contact at same level, consider touch
Do not disturb approach, set sufficient time aside, give your phone or pager to somebody
else.
Prepare yourself for the difficult task!!!
2. Perception of the patient: determining what the patient already knows and understands. What have
you been told about your medical situation so far? or What is your understanding of the reasons
we did the MRI?
Consider the patients cultural values and background!!!
3. Invitation: obtaining the patients invitation and to find out how much the patient wants to know:
would you like me to give you all the information or sketch out the results and spend more time
discussing the treatment plan?
When all the results are available, some patients want to know in details what the results are and
what they might expect in the short or long term. Other patients prefer not to be given this
information. How do you feel?
If patients do not want to know details, offer to answer any questions they may have in the future or
to talk to a relative or friend. Consider setting up a follow-up or second consultation!
4. Knowledge: giving information and knowledge to the patient (I am sorry to tell you that..).
Giving medical facts, the one-way part of the physician-patient dialogue, may be improved by a
few simple guidelines. First, start at the level of comprehension and vocabulary of the patient.
Second, try to use nontechnical words such as "spread" instead of "metastasized" and "sample of
tissue" instead of "biopsy." Third, avoid excessive bluntness (e.g., "You have very bad cancer and
unless you get treatment immediately you are going to die.") as it is likely to leave the patient
isolated and later angry, with a tendency to blame the messenger of the bad news. Fourth, give
information in small bits or chunks and check periodically as to the patient's understanding. Fifth,
when the prognosis is poor, avoid using phrases such as "There is nothing more we can do for you."
This attitude is inconsistent with the fact that patients often have other important therapeutic goals
such as good pain control and symptom relief.

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5. Empathising and exploring:

The emotions of the patient are important to consider (from silence to disbelief, crying, denial, or
anger), demonstrate an empathetic and sympathetic approach!
Encourage the person to express her/his feelings. People react in different ways to bad news, eg
with anger, denial, disbelief, sadness, self-pitty, dependeny, acute distress, shock or numbness.
Allow and encourage the person to express her/his feelings freely, eg by crying, talking about
concerns, fears, anger, anxieties, etc. Explore the main reasons for the emotion, eg can you tell me
what youre most worried about right now?
Make sure the patient gets the reassurance that such feelings are normal!
Emphasise that everything does not have to be covered in the one discussion.
6. Strategy and Summary: develop a clear plan with treatment options and checking the patients
understanding of the decisions at the end of the meeting. The aim is to EMPOWER the patient to
deal with the situation!
Depending on the situation, it is important to discuss potential recurrence, spread of disease and
treatment options including side effects (temporary or permanent) or what happens in case of
failure of treatment.
At some stage one should discuss the issue of respite and hospice care and even end of life and
not for resuscitation wishes.
Sometimes the question of genetic tests needs to be raised in the interest of other family members..
Offer assistance to talk to others if thats what the patient wants.
Make arrangements for the next appointment and indicate your availability at any time or other
resources and document your discussion.

Another mnemonic is:

BREAKS B Background, R- Rapport, E Explore, A Announce-; K-Kindling and S Summarize

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Examples of empathic, exploratory, and validating responses (the oncologist)

Empathic statements

I can see how upsetting this is to you.

I can tell you weren't expecting to hear this.
I know this is not good news for you.

I'm sorry to have to tell you this.

This is very difficult for me also.

I was also hoping for a better result.

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ExploratoryValidating
questions responses
I can understand
How do youhow you felt that
mean?
way.
I guess anyone
Tell me more
might have that
about it. same reaction.
Could you You were perfectly
explain what
correct
you
to think
mean?
that way.
Yes, your
understanding of
the reason for the
You said it
tests is very
frightened good.
you?
It appears that
Could you you've
tell
thought
me what you're
things through very
worried about?
well.
Now, you said
you were
Many other
concerned about
patients have had a
your children.
similar
Tell me more.
experience.