Knowing how to Break Bad News well is an essential skill for OSCEs but more crucially for future clinical practice. From an early stage, doctors find themselves in situations where they need to convey difficult news to patients and/or relatives.
Bad or distressing news is never easy to hear, but having someone deliver the news well can make the person receiving the news feel respected, cared about and supported going forwards.
Clinical Communication – General Tips
Prepare for the consultation (see ‘setting’ below)
This would also involve sufficient background reading to ensure you are up to date with the patient’s past medical history and recent events.
- Check you have the correct patient – confirm they are happy to be called by their name e.g. Joanna or Mrs Smith.
- Introduce your full name and role and purpose of the interview (e.g. ‘I have been asked to speak to you about some recent investigations you have had’)
- If you are seeing the patient instead of their usual doctor – apologise for the change/explain that you are stepping in for whatever reason. They may be expecting to have the conversation with someone else.
- Gain consent – check they are happy to discuss the topic with you
- Mention confidentiality if relevant
Display active listening skills:
- Maintain an appropriate level of eye contact throughout
- Open, relaxed, yet professional body language (uncrossed legs and arms, leaning slightly forward in chair)
- Nodding, acknowledging what the patient says
- Avoid interrupting the patient
Try to establish a rapport with your patient:
- Ask how they are, offer them a seat/glass of water
- Empathise with any emotion they display/verbalise and acknowledge the difficulty/stress of situations they could be experiencing (watch them carefully)
- Listen and respond to the things they say
Structuring the consultation
SPIKES is an effective way to structure your consultation. (Baile et al., 2000)¹
A comfortable, quiet and private room
- Although this is not always possible, make sure you have at least some privacy, and that the patient and family have somewhere to sit. Bad news should never be broken standing in a corridor!
- Have tissues available
- Ensure both you and the patient/relative are sitting down
- Arrange the chairs if necessary, e.g. at approx. 45 degree angles to each other – avoiding physical barriers between you and the patient (for example, a desk)
- Ensure you have uninterrupted time during the meeting (beepers, phones turned off)
Who else do you want in the room?
- Other healthcare workers can provide support in breaking the diagnosis, for example, nurse specialists
- Ask the patient if they want anyone to be with them – “Would you prefer to have a family member or friend here?”. Likewise, if there is someone else already in the room, check to see if your patient would prefer to be told alone.
Discuss the events leading up to now: scans, biopsies etc
Discuss any symptoms the patient may have been experiencing up to this point
Establish what the patient already knows or is expecting
Establish the patient’s current emotional state and if there is anything particular on the patient’s mind (any ideas, concerns or expectations the patient might have)
- “Could you tell me what’s happened so far?”
Here you could agree with the patient and say something like ‘Yes, the reason we wanted to do the tests were so we could find out why you have been experiencing the symptoms you just described to me. Were you aware of what sort of things the investigations might show?
The patient may or may not have been made aware of the possible diagnoses.
If they don’t know of the possible diagnoses – you could say something like this ‘ Symptoms like the ones you’ve been describing can sometimes be as a result of an infection, but sometimes they can be as a result of more serious underlying conditions’ This can also act as a warning shot.
Check if the patient wants to receive their results today – in an OSCE setting the answer will always be that they want to know the information now. However, on the wards be aware that some patients who may recognise the news may not be what they hoped for, may want to put it off until family are present, or after a holiday or family occasion etc
- “I have the result here today, would you like me to explain it to you now?”
Ensure you deliver the information in sizeable chunks, and regularly check for understanding.
Use a warning shot to indicate that you have unfortunate news:
- “As you know we took a biopsy/did a scan, and unfortunately the results were not as we hoped”
Allow a large pause if necessary, so the patient is able to digest what you have told them.
Then provide the diagnosis:
- (Using simple language)
- “I’m afraid/sorry to tell you this, but the results from the investigations show you have cancer”
- Chunk the diagnosis, pausing after each piece of information
- After giving the diagnosis, it’s wise to wait for the patient to re-initiate the conversation
“I’m afraid it’s not the news we were hoping for Mrs Brown”
“Unfortunately, the lump is due to a more serious underlying cause”
“I’m so sorry to tell you, but you have breast cancer”
PAUSE until the patient speaks, or after they seem to be ready to talk again. This may be a few minutes.
Make sure your tone is respectful, at a slow pace and clear
It is very natural for the patient to have an emotional reaction at this stage. They may go quiet, ask questions in disbelief, deny that this is happening, start crying, become hysterical or angry. These are all normal reactions to hearing bad news and each person will respond in their own way.
Give the patient TIME to have their emotional reaction. People often find it very uncomfortable watching patients like this but it is important to give the patient space to just react.
Questions in disbelief such as ‘This can’t be happening, can it?’ or ‘But how am I supposed to deal with this?’ are often asked to us at this stage. Make a judgement about whether you need to answer the questions directly. Saying something like ‘I’m so sorry I had to break this news to you today’ might be all you need to say at this point.
If they are making eye contact with you and asking questions like ‘So what will happen next?’ then it is probable that they are ready to receive answers to their questions.
EMOTIONS AND EMPATHY
- Recognize and respond to emotions with acceptance, empathy and concern
- Acknowledge and reflect their emotions and body language
- Do not lie when the patient asks questions about prognosis – it is not kind to give false hope
- If you do not know information, tell them that, and suggest that you can refer their case to a specialist or that more information is needed
“I’m so sorry, but at this stage, I don’t have enough information to answer that. Hopefully in the next few weeks once we’ve completed other tests I can be clearer. Sorry, I can appreciate that it’s frustrating to be left with unanswered questions”
- “I can see this is a huge shock for you”
- “I can see that this is not the news that you expected, I’m so sorry”
STRATEGY AND SUMMARY
- Make a plan together to meet the patient again/inform them of what the next step is
- Reassure the patient that they are going to/have been referred to the appropriate team of specialists who are best equipped to come up with a plan going forward
- Try not to rush the patient to make decisions about their treatment (if possible), it is respectful and considerate to let them process what has been told to them
- Check the patient’s understanding
- Summarise: Respectfully and gently repeat any important points – patients who are shocked or upset will not take in much information
- Ensure to answer any questions or concerns that can be addressed at this stage (and listen out for any implicit ones)
- Offer ongoing assistance to the patient should they think of any further questions – this may involve giving them details of a clinical nurse specialist
- Offer assistance to tell others (e.g. other family members) the bad news
- Highlight where the patient can go to gather more information or gather any support (support groups, websites)
- Offer written materials if relevant and available
- Asking about religious preferences, and whether the patient would like the Chaplain
- In some situations, exploring the relatives thoughts on organ donation is a good opportunity, and people often see organ donation as their relative’s death meaning life for someone else
When the consultation is over:
Be aware that breaking bad news can be emotionally challenging for us healthcare professionals also – particularly if you have built a rapport with the patient.
Think through your own thoughts, and reflect on how you’re feeling. Take time out if needed.
- Breaking bad news is not something you only do in the context of cancer. There are a wide variety of possible situations in which the strategies discussed here can be applied to (e.g. STD results / diagnosis of type 1 diabetes / miscarriages)
- Think about how a patient might feel when giving them any new information about their condition, and how it may impact their lives
- Use the correct language – cancer is cancer, death is death. It is important that there is no ambiguity about what the diagnoses/results show
- Avoid euphemisms and ensure to avoid any medical jargon
1. Baile, W., Buckman, R., Lenzi, E., Glober, G., Beale, E., & Kudelka, A. SPIKES – a six step protocol for delivering bad news: Application to the Patient with Cancer. Oncologist 2000; 5(4):302-311.