11/13/24, 8\:16 PM Guide | Breaking bad news

Breaking bad news

Table of contents
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Introduction

Knowing how to break bad news well is an essential skill for OSCEs and clinical practice. From an early stage, doctors
themselves in situations where they need to convey di
easy to hear, but having someone deliver the news well can make the person receiving it feel respected and supported going
forwards.

General tips

Prepare for the consultation by choosing an appropriate environment (see the ‘setting’ section below) and performing su
background reading to ensure you have a good understanding of the patient's situation.

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself including your full name and role.
Check you have the correct patient and con
Explain the purpose of the interview (e.g.
‘ I h a v e b e e n a s k e d t o s p e a k t o y o u a b o u t s o m e r e c e n t i n v e s t i ga t i o n s y o u h a v e h a d .
’ ).
If you are seeing the patient instead of their usual doctor – apologise for the change and explain that you are stepping in for
whatever reason.
Gain consent to discuss the topic with the patient and explain that the discussion will be con
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Active listening

Display active listening skills throughout the consultation\:
Maintain an appropriate level of eye contact throughout.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Nod to acknowledge what the patient is saying where appropriate.
Avoid interrupting the patient throughout the consultation.

Establish rapport

Try to establish a rapport with your patient\:
Ask how they are, o
Empathise with any emotion they display/verbalise and acknowledge the di
experiencing (watch them carefully).
Listen and respond to the things the patient says.

Structuring the consultation

SPIKES is an e
¹

Setting

It's important to break bad news in an appropriate setting\:
The discussion should occur in 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!
Make sure to have some tissues available.
Ensure both you and the patient/relative are sitting down.
Arrange the chairs if necessary (e.g. at approximately 45-degree angles to each other), avoiding physical barriers between
you and the patient (e.g. a desk).
Ensure you have uninterrupted time during the meeting (turn o
Other people who may be helpful to have in the room when breaking bad news\:
Other healthcare workers can provide support in breaking the diagnosis, for example, a nurse specialist.
Ask the patient if they want anyone to be with them\:
“ W o u l d y o u p r e f e r t o h a v e a f a m i l y m e m b e r o r f r i e n d h e r e ?”
. Likewise, if
there is someone else already in the room, check to see if your patient would prefer to be told alone.

Perception

emotional state.
Begin by discussing the sequence of events leading up to this point (e.g. scans, biopsies, etc) and assess the patient's current
Ask about any symptoms the patient may have been experiencing up to this point. Here you could agree with the patient and
say something like\:
" Y e s , t h e r e a s o n w e w a n t e d t o d o t h e t e s t s w e r e s o w e c o u l d
s y m p t o m s y o u j u s t d e s c r i b e d t o m e . W e r e y o u a w a r e o f w h a t s o r t o f t h i n gs t h e i n v e s t i ga t i o n s m i gh t s h o w ?"
Establish what the patient already knows or is expecting, 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\:
" S y m p t o m s l i k e t h e o n e s y o u’ v e b e e n
d e s c r i b i n g c a n s o m e t i m e s b e a s a r e s u l t o f a n i n f e c t i o n , b u t s o m e t i m e s t h e y c a n b e a s a r e s u l t o f m o r e s e r i o u s u n d e r l y i n g
c o n d i t i o n s"
. This can also act as a warning shot.

Invitation

Check if the patient wants to receive their results today - in an OSCE setting the answer will always be yes, however, on the
wards, be aware that some patients may recognise the news may not be what they hoped for and may want to put it o
family are present\:
“ I h a v e t h e r e s u l t h e r e t o d a y , w o u l d y o u l i k e m e t o e x p l a i n i t t o y o u n o w ?”
.

Knowledge

Ensure you deliver the information in sizeable chunks, and regularly check the patient's understanding.
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Use a warning shot to indicate that you have unfortunate news\:
t h e r e s u l t s w e r e n o t a s w e h o p e d”
.
“ A s y o u k n o w w e t o o k a b i o p s y / d i d a s c a n , a n d u n f o r t u n a t e l y
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\:
h a v e c a n c e r”
.
“ I’ m s o r r y t o t e l l y o u t h i s , b u t t h e r e s u l t s f r o m t h e i n v e s t i g a t i o n s s h o w y o u
Deliver information in chunks, pausing between each piece of information. After giving the diagnosis, it's wise to wait for the
patient to re-initiate the conversation.
Example
“ I’ m a f r a i d i t’ s n o t t h e n e w s w e w e r e h o p i n g f o r M r s B r o w n .
”
PAUSE
“ U n f o r t u n a t e l y , t h e l u m p i s d u e t o a m o r e s e r i o u s u n d e r l y i n g c a u s e .
''
PAUSE
“ I’ m s o s o r r y t o t e l l y o u , b u t y o u h a v e b r e a s t c a n c e r .
”
PAUSE until the patient speaks, or seems ready to talk again.
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
is important to give the patient space to react.
Questions in disbelief such as " T h i s c a n' t b e h a p p e n i n g , c a n i t ?" or " B u t h o w a m I s u p p o s e d t o d e a l w i t h t h i s ?" are often asked at
this stage. Make a judgement about whether you need to answer the questions directly, saying something like " I' m s o s o r r y I
h a d t o b r e a k t h i s n e w s t o y o u t o d a y
" might be all you need to say at this point.
If they are making eye contact with you and asking questions like " S o w h a t w i l l h a p p e n n e x t ?" then it is probable that they are
ready to receive answers to their questions.

Emotions and pathway

Recognize and respond to emotions with acceptance, empathy and concern. Acknowledge and re
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 s o s o r r y , b u t a t t h i s s t a g e , I d o n' t h a v e e n o u gh i n f o r m a t i o n t o a n s w e r t h a t . H o p e f u l l y i n t h e n e x t f e w w e e k s o n c e w e' v e
c o m p l e t e d o t h e r t e s t s I c a n b e c l e a r e r . S o r r y , I c a n a p p r e c i a t e t h a t i t' s f r u s t r a t i n g t o b e l e f t w i t h u n a n s w e r e d q u e s t i o n s'
'
.
Some useful phrases may include\:
“ I c a n s e e t h i s i s a h u g e s h o c k f o r y o u”
“ I c a n s e e t h a t t h i s i s n o t t h e n e w s t h a t y o u e x p e c t e d , I' m s o s o r r y''

Strategy and summary

Make a plan together to meet the patient again and inform them of what the next steps are.
Reassure the patient that they are going to be referred to the appropriate team of specialists.
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 of the bad news you have delivered.
Summarise\: respectfully and gently repeat any important points – patients who are shocked or upset will not take in much
information.
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Ensure to answer any questions or concerns that can be addressed at this stage (and listen out for any implicit ones).
O
clinical nurse specialist.
O
Highlight where the patient can go to gather more information or gather any support (support groups, websites).
O
If appropriate, consider asking about religious preferences, and whether the patient would like the Chaplain.

After the consultation

Dispose of PPE appropriately and wash your hands.
Be aware that breaking bad news can be emotionally challenging for you as a healthcare professional, particularly if you have
built a rapport with the patient.
Think through your own thoughts, and re

General points

Breaking bad news is not only done 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. sexually transmitted infection 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 results
show.
Avoid euphemisms and medical jargon.

References

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.
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Source\: geekymedics.com
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