How to break BAD NEWS to your patient.

Communicating bad news to patients well is not an optional conversation; it is an essential skill of professional practice.

At some time most of us will get to break bad news to our patients or their families.
Bad news may cover a range of scenarios including disclosing a medical diagnosis, or informing of a death.
If we are not actually breaking it, we may be there to offer support and guidance during this most intimate of times.
Despite the deep importance of these conversations, breaking bad news is something that is not often taught to nurses or doctors. We often learn how to do it through watching our peers, or through trial and error.

As a result it can be a stressful and emotionally confronting experience. In a worse case scenario, important information might be avoided all together or incorrect messages (both verbal and non verbal) may be given about things such as prognosis or severity.

When we prepare to deliver bad news, our minds often become crowded with our own concerns around:

  • Balancing the situational evidence with our intention of not destroying all hope.
  • Fear about the anticipated reactions to the news.
  • Fear about our own emotions spilling into the conversation.

Here is rough guide to some of the important skills in breaking bad news.
They are a combination of my own experiences and information provided in an excellent publication by the Department of Health, Social Services and Public Safety in Belfast.

Prepare yourself:

Patients and their families want to be told bad news attentively.
That is, they want you to be honest, compassionate, informative and available (that is, not pressured and hurrying off to do other things, but willing to stay and talk at the pace the person needs).

  • Familiarise yourself with the person(s) you are about to talk to.
    Try to know their name(s).
    Will there need to be any special preparations made for this conversation such as interpreters?
  • Mentally rehearse the conversation.
    Consider the questions you are likely to be asked.
    Remember that although the information you may be giving may be very sad, it is also very important.
  • Consider confidentiality and disclosure when discussing information about a patient with their family. Family members should not be given any information that the patient themselves is not yet aware of or has not consented to (assuming they are able to understand this information).
    Consideration should also be to the confidentiality of any medical information that may be disclosed.
  • Take a few moments to settle and relax your own emotions. Take a few deep slow breaths.
  • It is recommended that you always have a second colleague present to support both you and the recipients of the news.

Prepare the setting:

  • Arrange for a private room to have the discussion if possible.
    Unfortunately sometimes delivering bad news in a busy clinical setting is unavoidable. In such instances everything should be done to maximise privacy and dignity, and to minimise interruptions and sensory overload during the conversations.
  • Consider having tissues and some water available
    Small things that make a big difference.

Breaking the news:

There is no easy way to do this.
Some advocate for warning the person(s) about to receive bad news by opening with something such as, Unfortunately I’m afraid I have some bad news to tell you“ or ”I am sorry to have to tell you this”.
This provides the person(s) a cue as to the importance of what is about to follow, giving them a better chance to process the information.

  • Communicate at the level of comprehension and vocabulary of the patient.
  • Use non-techncial words and descriptions.
  • Provide information simply and honestly avoiding excessive bluntness.
  • Give the information in small chunk-lets, and give them time to process. Check for understanding.
  • Encourage questions and allow time.
    If the person(s) remain silent consider open ended questions to help them articulate their emotions (if they wish).
    Remember that much of this conversation may not be remembered and the information may need to be repeated at a later time.
    Providing written information around some topics may be useful.
  • Prepare for any reactions. These may range from quiet silence, to screaming, to physical violence (which is rarely aimed at other people).
  • Do not say things such as “I know how your feel” or “there is nothing more we can do”, because you don’t… and there is.

Is it OK to show my emotions during this conversation?
Yes. Patients and their families want an authentic conversation.
However, it is my experience that during the initial conversation what is needed is calm, clear concise information.

During this time a certain detached professionalism may be the best way to ensure the information is transmitted.

Once there has been some time for the message to be received and processed, the encounter becomes much more open and fluid. It may then be completely appropriate for you to open to your own emotions of this experience.
It is what it is.

After the conversation:

Breaking bad news is only the beginning. The most important thing is to make sure there is a continuity of support and attentiveness after the news has been broken.
Things to consider include:

  • Does the person(s) have a good support network after they leave the hospital?
  • Do they have all the necessary information and documentation they need.
  • Are they able to contact someone (preferably a member of staff they have had close contact with) if they have any questions or concerns down the track?

Do not forget to document the conversation in the patient notes. Include a record any important questions or details that were exchanged, and any further needs that must to be followed up on.

Finally, it is important that staff involved in breaking bad news have an opportunity to informally debrief as a group (if they wish), and to be able to reflect and to have access to discuss the experience with mentors or peers as soon as possible after the event.


Reference:

  1. Breaking Bad News.Regional Guidelines. [Internet]. [cited 2013 Nov 10]. Available from: http://www.dhsspsni.gov.uk/breaking_bad_news.pdf

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