breaking bad news

BY
K.R. PERAMASAMY CRRI
DEPT OF PSYCHIATRY

 “Any information which adversely and
seriously affects an individual’s view of
his or her future”
 Bad news always, depends on the
recipient’s expectations or understanding.

 Patients Want the Truth
 A Frequent but Stressful Task
 Clinical Outcomes
 Ethical and Legal Imperatives

 The Bearer of bad news often experiences strong
emotions such as anxiety, a burden of responsibility
for the news, and fear.
 This stress creates a reluctance to deliver bad news,
which is called the “MUM” effect. The MUM effect is
particularly strong when the recipient of the bad
news is Already distressed.
 Lack of training, guidelines, experience of the
physician.

 To make a plan
 Increase physician confidence.
 Encourage patients to participate in difficult
treatment decisions.
 Less stress and burnout.

 Gathering information from the patient.
This allows the physician to determine the patient’s
knowledge and expectations and readiness to hear the
bad news.
 Provide clear information in accordance with the
patient’s needs and desires.
 Support the patient by reducing the emotional
impact and isolation experienced by the recipient of
bad news.
 Develop a strategy in the form of a treatment plan
with the input and cooperation of the patient.

 Mental rehearsal is a useful way for preparing for
stressful tasks.
 Although bad news may be very sad for the
patients, the information may be important in
allowing them to plan for the future.
 Arrange for some privacy
 Involve significant others
 Sit down, provide comfortable space.
 Establish good rapport
 Manage time constraints and avoid interruptions

 Prepare before speaking. BEFORE U TELL ASK
 Before discussing the medical findings, the clinician uses open-
ended questions to create a reasonably accurate picture of how
the patient perceives the medical problem.
 Based on this information you can correct misinformation and
tailor the bad news to what the patient understands.
 It can also accomplish the important task of determining if the
patient is engaging in any variation of illness denial.

 Ask questions to invite the patient into conversation.
 While a majority of patients express a desire for full information
about their diagnosis, prognosis, and details of their illness, some
patients do not.
 When a clinician hears a patient express explicitly a desire for
information,it may lessen the anxiety associated with divulging
the bad news.
 Shunning information is a valid psychological coping mechanism
which can be manifested as the illness becomes more severe
 If patients do not want to know details, offer to answer any
questions they may have in the future or to talk to a relative or
friend.

 Warning the patient that bad news is coming may lessen the
shock. Begin with “I’m sorry to tell you that…”.
 First, start at the level of comprehension and vocabulary of the
patient. Use plain language.
 Second, try to use nontechnical words such as “sample of tissue”
instead of “biopsy.”
 Third, avoid excessive bluntness, mind body language.
 Fourth,give information in small chunks and pause, check
periodically as to the patient’s understanding.
 Fifth, when the prognosis is poor, avoid using phrases such as
“There is nothing more we can do for you.”
 use teach back” to verify that the message was received.

 Patients emotional reactions may vary from silence to disbelief,
crying, denial, or anger and express shock, isolation, and grief.
 In this situation the physician can offer support and solidarity to
the patient by making an empathic response.
An empathic response consists of four steps-
 First, observe for any emotion on the part of the patient.
 Second, identify the emotion experienced by the patient. If a
patient appears sad but is silent, use open questions to query the
patient as to what they are thinking or feeling.
 Third, identify the reason for the emotion. This is usually
connected to the bad news. However again, ask the patient.
 Fourth, give the patient a brief period of time to express his or
her feelings let the patient know that you have connected the
emotion with the reason for the emotion by making a connecting
statement.

 Doctor: I’m sorry to say that the x-ray shows that
the chemotherapy doesn’t seem to be working [pause].
Unfortunately, the tumor has grown somewhat.
 Patient: I’ve been afraid of this! [Cries]
 Doctor: [Moves his chair closer, offers the patient a
tissue, and pauses.] I know that this isn’t what you
wanted to hear. I wish the news were better.
 In the above dialogue, the physician observed the
patient crying and realized that the patient was tearful
because of the bad news. He moved closer to the
patient. At this point he might have also touched the
patient’s arm or hand if they were both comfortable
and paused a moment to allow her to get her
composure. He let the patient know that he understood
why she was upset.

 Until an emotion is cleared, it will be difficult to go on to discuss
other issues.
 If the emotion does not diminish shortly, it is helpful to continue to
make empathic responses until the patient becomes calm.
 Again, when emotions are not clearly expressed, such as when the
patient is silent, the physician should ask an exploratory question
before he makes an empathic response.
 combining empathic, exploratory, and validating statements is
one of the most powerful ways of providing that support .
 It reduces the patient’s isolation, expresses solidarity, and
validates the patient’s feelings or thoughts as normal.

Empathic statements Exploratory questions Validating responses
“I can see how
upsetting this is to
you.”
“Tell me more about
it.”
“I guess anyone might
have that same
reaction.
“I know this is not good
news for you.”
“Could you explain
what you mean?”
Many other patients
have had a similar
“experience.”
“This is very difficult
for me also.”
Could you tell me what
you’re
“worried about?”
“I can understand how
you felt that way.”
“I was also hoping for a
better result
Now, you said you were
concerned about
“your children. Tell me
more.”
You were perfectly
correct to think that
way

 Assess patients readiness for planning
• Negotiate next steps
• Acknowledge and answer questions
Summarize plan
• Use “teach back” technique
• Follow up.

 Before discussing a treatment plan, it is important to ask patients
if they are ready at that time for such a discussion.
 Presenting treatment options to patients when they are available
is not only a legal, but it will establish the perception that the
physician regards their wishes as important.
 Sharing responsibility for decision-making with the patient may
reduce the sense of failure on the part of the physician when
treatment is not successful.
 Clinicians are uncomfortable when they discuss prognosis and
treatment options with the patient, if the information is
unfavorable.

 These difficult discussions can be greatly facilitated by using
several strategies.
 First, many patients already have some idea of the
seriousness of their illness and of the limitations of treatment
but are afraid to bring it up or ask about outcomes.
Second, understanding the important specific goals that many
patients have, such as symptom control, and making sure that
they receive the best possible treatment and continuity of care
will allow the physician to frame hope.
This can be very reassuring to patients.

“If we do it badly,
the patients or family members
may never forgive us, and
if we do it well,
they may never forget us”.

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