This is a UKMLA-centred article about breaking bad news.

Introduction

• Breaking bad news is a crucial skill to practice for exams and clinical practice.
• At any stage in their training, doctors will find themselves conveying difficult information to patients and/or family members.
• To be able to communicate distressing news requires sufficient preparation and practice which we will cover in this article.
• A helpful acronym, SPIKES may be used to structure the consultation to ensure all tasks are met.

S – Setting the scene

Firstly, before you speak to the patient it is important to choose an appropriate setting to initiate the consultation. In a hospital this is normally a side room or an enclosed space where there is privacy. Aim to have both the patient and yourself sitting down with chairs at a 45 degree angle which would help to put them at ease. Ensure you have sufficient knowledge of the information you would like to deliver to the patient to be able to support the patient going forwards and answer any questions they may have. If appropriate, you can ask the patient if they would like anyone in the room with them, either a family member of a relevant healthcare professional.

Ensure you introduce yourself, check the patient’s details, explain the purpose of the consultation and gain consent to proceed.

P – Perception

It is a good idea to begin by discussing the patient’s level of understanding of why they are here and their current knowledge about their health journey. This will give you a good standpoint to know how to continue with the consultation.

I – Invitation

Ask the patient whether they wish to know the details of their medical condition/situation. In exams, the answer will always be yes but in reality patients may choose to not want to hear bad news until at a later stage when they are ready.

K – Knowledge

It is important to remember these things when delivering the bad news:

• Do not jump straight into the bad news, always prepare the patient by telling them you have unfortunate news. This can be best done by referring back to what the patient knows then transitioning into what you know now.
• Use simple language that the patient can understand, not medical jargon.
• Deliver the information in sizeable chunks as when patients are upset it can slow down rate of comprehension.
• Allow the patient time to grieve and make them comfortable with pauses so they have space to react.
• Do not give false hope that will make them feel better momentarily. This can be seen as lying and potentially be used against you in the future.

E – Emotion

Recognising and responding to the patient’s emotions is key. People react in a variety of ways, they may have an outburst of grief, become angry or fall silent to bad news. Being able to respond to these is important. 

Identifying the source of emotion will be important to know how to react effectively. Most of the time, allowing the patient to express their feelings and then giving an empathetic response will make them feel heard. Additionally, do not underestimate the importance of active listening. Most of the time patient’s want to feel listened to rather than being spoken to. 

It is important to respect the patient’s preferences and to involve them in the decision-making process. This includes discussing the options available for managing the situation, and emphasizing the importance of making a decision that feels right for the patient. 

S – Summary

Being prepared to close the consultation is just as important as opening the consultation. Remember to always ask them if they have any questions or want any further clarification. At this point the patient would have had some time to adjust to the bad news so may have many questions for you. 

Before you end, offer an agenda for the next meeting. This will make the patient feel safe knowing that there is a clear plan moving forward. This could be arranging another consultation, referring the patient onto a specialist and/or signposting them useful links/leaflets that will explain things in more depth. 

Breaking bad news can be a difficult and emotional experience for both the healthcare professional and the patient. Whether it is a diagnosis of a serious illness, a change in a patient’s condition or the loss of a pregnancy, delivering bad news requires sensitivity, empathy and a clear and concise approach. By following these steps, healthcare professionals can help to reduce the emotional impact of bad news and support the patient through the difficult process.

References

1. https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/reflective-practice/breaking-bad-news

2. https://northyorkshireccg.nhs.uk/wp-content/uploads/2021/02/Top_tips.pdf

3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5578619/

Author – Mohona Sengupta  

Editor – James Mackintosh

Last updated 20/05/23