Breaking Bad News

As a junior doctor, you will have face situations where you have to convey potentially distressing information, whether it is explaining a diagnosis or blood results to a patient or giving difficult news to relatives. Breaking bad news well is an essential communication skill which can strengthen the relationship between a patient and a doctor and create an environment where the patient and/or their families feel respected and supported.

As an FY1 you should not be breaking news about a terminal diagnosis (unless you feel comfortable to do so). The reasons for this is you’re unlikely to have expertise on further steps, management & prognosis. That said FY1s are on the ward the most, therefore, may have the best rapport with the family, which may make them better able to give bad news. Before even approaching the patient or applying the SPIKES model below, you should have complete & up to date knowledge on what has occurred and what is likely to occur next. You should be able to respond to the dreaded “how long do they have left?” or “are they going to die?”.

The SPIKES protocol developed by Baile et al., 2000 is a six-step framework designed to help doctors to deliver bad news and is as follows:

S – Setting up the interview

  • It is important to find a private place on the ward, whether it is the family/ quiet room on the ward or a side room. If you aren’t sure of where this is on the ward as a staff nurse for the best place for you to have a private sensitive discussion. Avoid breaking bad news in a corridor. 
  • Minimise interruptions. If possible, give your bleep to a colleague to hold on to and let the nurses know what you are doing. 
  • It can be useful to have a nurse or healthcare worker in the room with you to offer support to the patient/ family. 
  • Introduce yourself to the patient/ family and introduce any additional colleagues present. When speaking to a patient you can ask if they would like to have this discussion with a family member or friend present. If any relatives/ friends present then clarify their relationship with the patient. 

P – Perception

  • It is important to elicit the patient and/ or relative’s perceptions and understanding of what is going on and how much they are aware of. 
  • Good ways to ask are: ‘What have you been told so far?’, “Can you tell me what has been happening so far?’.
  • This is a good opportunity to ascertain their ideas, concerns and expectations.
  • From this, it is possible to identify which patients may be in denial or need additional support in receiving a difficult diagnosis. 
  • What you might find “bad news” might not be what the patient perceives as bad news. It is best to be on the safer side, but the best way to appreciate a patient’s perceptions is to ask!

I – Invitation

  • Invite the patient and/or relatives to ask questions and check how much they want to know and whether. 

K – Knowledge

  • Warning shot – it is a good idea to give an indication to the patient/ relative that you are going to give some difficult news. 
  • This needs to be handled carefully, for example, you can say ‘The results of the scan/ blood tests/ biopsy are back and unfortunately they are not as we had hope for. I’m sorry to tell you that the results/ tests show…’
  • Explain diagnosis/ result in clear, simple language (avoid medical jargon). Deliver the information in sizeable chunks with long pauses in between. This gives a chance for patients to assimilate the information and to ask questions.
  • Give time after giving the initial diagnosis/ test result and wait for the patient/ relative to initiate the conversation. 
  • Repeat important points as it can be hard for anyone to take on further information after receiving distressing news. 

E – Emotions / Empathy

  • Be open and honest with patients, it is important not to give false hope.
  • Acknowledge their reactions which can vary from silence, grief or anger and how difficult the situation is for them with empathy and respect. 
  • Address the fact that you have given them a lot of information to take on board and offer opportunities to ask questions or to re-visit this discussion at a later date if needed.

Strategy and Summary

  • It is often easier for patients/family to take on board upsetting news if there is a clear plan of action ahead that both parties (the clinical team and the patient/ family) can agree to. This plan can take the form of a treatment plan, or arranging further discussions in the future to discuss prognosis and, if appropriate, end of life management. 
  • Do not rush patients into making decisions about management and give time for them to think it over. 
  • Summarise information again and offer written materials if appropriate. 

Breaking bad news can be exhausting and it may be a good idea to debrief with your colleagues afterwards.

By Dr Ibtisam Hasan ST1

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