INFORMATION FOR CANDIDATE

You are the ICU resident, a patient has just died

and the family arrived and they want to know
what has happened. You are supposed to explain
to a medical student how you prepare to break
the bad news to the family.
YOUR TASK IS TO: explain to the medical
student, John, the principles of breaking bad
news

Delivering

Bad

News

Delivering or breaking bad 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 practitioner, 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!. It is important to convey the right level of information, in
understandable terms, at the right pace and at the right time, as determined by the patient.
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).
Patients have the right to information and experience shows that often patients want to
find out more than doctors think.

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, can be very difficult on
the telephone (Recommend people not to drive to the hospital, because they could
be at risk of an easy accident!)..
!!!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 of the situation and what
the patients pre-existing concern is or what the bad news might be before you
start, e.g.
Whats your understanding of whats been happening? or
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.

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?
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!

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:
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, 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!!! 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!
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.
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.
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. repeat important information, even 2x or 3x
2. stress significant material
3. use physical (pointing to an area on the body) and written
prompts
4. summarise
5. ask patient to reflect understanding
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
This is your fault
extreme guilt
What could I have done better?
sadness
helplessness

despair
guilt
bargaining
adaptation and acceptance

why me?
could we have prevented this?

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:
It must have been a frightening experience for you
SYMPATHY:
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
.

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, 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.
Encourage the patient to write a list of all the significant questions they have so
they can be discussed

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 follow-up.
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.

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

Another mnemonic is called the SPIKES protocol (Compiled By :SUHAIL WANI):

:

S- Setting
P-Perception
I-Invitation
K-Knowledge
E-Emotions
S-Strategy
1) Setting/Strategy:

Sit Facing The patient,Make sure there are no physical barriers

between you & patient e.g a table
Respond according to the setting in the station e.g
Emergency,GP clinic,etc.make sure you take care of patients
privacy. Stay calm.
Use appropriate language e.g How are you feeling today
rather than How are you today.

2)Perception:

E.g. A Breast cancer:You had a lump in your breast since 2

months.What do you think is going on.What do you think is
causing it

[This helps you to know patients perception about the condition & patients
expectations so you can respond accordingly]
3)Invitation: Invite the patient about disclosing the information & how he would
like to handle it:

How would you like me to handle the information about what is going
on?.Are you the person who wants to know everything in detail.
Is there a family member or a friend along with you so want me to
share it with both of you
[ This gives an indication to the patient & prepares him that
the news is not so good]

4)Knowledge;

Introduce the newsWell we have got the results of your

tests,Biopsy..etc.
I am afraid the news is not as good as we were hoping for/I
have rather a bad news for you
Disclose the condition truthfully but be sensitive

What we are looking at is a cancer,or unfortunately we have

found the lump is malignant rather than..you have a Cancer
o
o
o

SILENCE:Give time for the news to sink

in..this is a very important thing to do..
Watch your NON VERBAL gestures..Be empathic
Offer some tissue if the patient or relative cries.
Tell the patient if he/she wants to discuss about the
condition on a next appointment.Remember It s hard for
a human to understand anything you would be saying
when he /she hears a bad news.
Normally the role player would let you continue so that you
finish the station

Generally human response for such a news follows a cycle..let

the person go through that cycle gradually & stepwise; They
are;

DANDA

D- DenialThis is what you would immediately see after breaking

the news..statements like I cant believe it,I had a small lump &
thats it..This isnt realy happening to me
A-Angeroften asked by patient as Why Me
N-Negotiation- Adress their fears & worries
D-Depression/hopelessness- Sadness,Grief,,guilt,Self Blame

A-Acceptance-All these form the part of dealing with

protocol

EMOTION

part of

SPIKES

To help yourself on such issues you can respond in the following way;
Respond to patients reaction :- I can see this as a terrible
shock, I know it is difficult to take in, I know it is a lot to take in
all at once

Remedies to deal with above:

Denial:

e.g the tests could be wrong/sometimes they make

mistakes,dont they
Respect their denial but dont encourage it or follow it
Openly ,gently & softly communicate facts in a neutral
manner Of course there is an outside chance of

mistake, but I think we must assume the tests are

correct

Anger: ..Often statements like Why me

Use phrases like

I can Understand that you are angry,..Its normal to be angry, you have a right
to be angry..
Bad things sometimes occur just by themselves,There is nothing wrong that
you did,There isnt anything for sure that you didnt do that could have prevented it
My goal for you is to make you as comfortable & functional as possible

Negotiation/Hopelessness;
Patients usually have a fear of Suffering, pain, abandonment, being burden to their
family,fear of moment of death etc.
Remedy

Address their fears & worries. Ask What concerns you most
about your illness
Inform about long & short term prognosis
What new symptoms & signs will appear
Alleviate suffering such as pain, nausea, dyspnea
Use phrases like..

We might not be able to cure the condition, but we can manage it effectively.
This is a serious condition but there are a lot of things that we can do to manage it.
Many people with this condition are living successful& productive lives.

Acceptance:
Patients need someone to encourage them to accept their ailment & doctor is the best
one;
Provide a plan
what we need to do 1st and then..
What we are going to do is
First of all we are going to organiseThen I will like you to
Do practice thee steps & you will cruise through this station..Just remember be
Empathic,Pause in between allowing patient to understand what you are saying, & show
concern for the patient & most importantly keep practicing as much as you can.