Giving Bad News: An Effective Three-Step Approach

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“Breaking bad news is not as much a delivery as it is a dialogue between
two people.”
— Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients who
suffer. West J Med 1999;171:260-3.

One of the most difficult tasks for a healthcare professional is to
deliver bad news.  It is never an easy activity even for the most seasoned
of professionals.  However, there are steps we can take to be sure the
news is delivered in the most effective and caring manner.

The Definition of “Bad News”

We tend to think of bad news as telling a patient they have a terminal
disease.  However, that is a type of bad news.  There are multiple types
of bad news.  For example, telling a construction worker he can’t lift
heavy objects for six months is bad news if that is his livelihood.  Also,
telling a person they have a chronic disease, such as diabetes, is also a type of
bad news.

Bad news can be any type of news that will negatively impact a patient in
any way.

Is it Always Necessary to tell a Patient the Bad News?

Fifty years ago, it would not be unusual to withhold a terminal cancer
diagnosis from a patient.  However, recent studies have shown that
patients do want to know this information.  It is important that patients
are given all the details of their health situation; they have a right to
know.  They may want to make decisions regarding wills and other legal
matters.

Based on a case-by-case basis, there may be situations where withholding
information may be a good option, such as in the case where a patient may
have a mental breakout or harm themselves.  In some cases, the patient
themselves may ask not be told.  This should be looked at as a type of
informed consent.

Steps in Giving the Bad News

I. Before Giving the News

Think about the agenda before you meet the patient, so that you have the
significant information available. There are several items to consider
when planning what to say:  specific diagnosis, treatment plans,
prognosis, and support strategies. For a patient who has been shown to
have hypertension, this would be an appropriate manner of discussing:
specific diagnosis (describe diagnosis of high blood pressure, avoid
medical jargon like the term hypertension), treatment plans (discuss
different options to treat high blood pressure), prognosis (discuss
successful options for treating, however be careful of not guaranteeing
100% success), and support strategies (provide resources to help cope).

Prepare for the conversation with the patient.  Think about what you want
to say.  Mentally rehearse your words so you feel more comfortable sharing
the news.

Have a box of tissues in the room in case the patient begins to cry.

II. Giving the News

Physical setting: Find a quiet private place to share the news.  Be sure
you are seated at eye level with the patient.  Avoid any physical
barriers, such as a desk.  Ask the patient who else should be present; let
the patient decide who, if anyone, should be present in the meeting.
Silence all beepers and request no interruptions unless it is an absolute
emergency.

Communication strategies:
* Give the patient a warning that difficult news is forthcoming, such as by
stating, “I’m afraid the results reveal the situation is more serious than
we would have hoped for …”)
* The patient is your first priority, however if the patient has other
people present (e.g., spouse), be sure to attend to those people as well.
* Speak slowly, clearly and concisely.
* Provide the information in small chucks; do not give a long lecture which
can be overwhelming to an already anxious patient.
* After discussing each segment, pause to allow the patient to take in what
you have stated.  This is known as “chunk and check.”
* Be honest about the prognosis; do not give false hope.  Be sensitive, yet
direct.
* Use empathy in the discussion (e.g., “I know this is difficult news.”)

Assess current level of knowledge.  Determine how much the patient already
knows, such as by asking, “What have you already been told about your
illness?” Pay close attention to what the patient says to evaluate their
level
of sophistication regarding the illness and their current emotional state.

Ask the patient how much they would like to know.  Inquire as to whether
they want all the details or just the “big picture.”  Emphasize the
fluidity of the dialogue, so they know they could always ask more
questions at a later time.

III. After Giving the News

Be very attentive to the patient’s feelings.  After you have shared all the
news, listen very carefully to the patient’s reaction while observing body
language.  Use empathy (e.g., “I know this has been very stressful to hear.”)

Emphasize your role as a partner.  Let the patient know you are working with
him or her on this medical issue (“We will be working together to help
you.”).  Confirm your role as an advocate for the patient.

Follow up plan.  This is a time for reviewing, summarizing and making next
steps.  Develop a step-by-step plan, review the plan with the patient and
then agree on follow up plans.  Provide resources, which could be a
referral to a counselor (if needed), brochures, phone numbers and
websites.

Closing Thoughts

Healthcare professionals are taught technical skills to attend to the
patients’ physical needs.  However, when giving bad news, the greatest
skill is effective communication.  Unfortunately, during a healthcare
professionals’ formal education, communication skills are often not given
the vital importance they deserve.  A growing body of evidence illustrates
how the communication skills of the healthcare professional will greatly
influence how well a patient will cope with the bad news.

Edward Leigh, MA, is the Founder and Director of the Center for Healthcare
Communication.  To book one of his high-content energetic keynote
speeches or training programs, visit or call:
http://www.CommunicatingWithPatients.com or call 1-800-677-3256

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