DR Ruvaiz Haniffa: Dept. Family Medicine, Faculty of Medicine, University of Kelaniya 25 September 2006

Breaking Bad News

Dr Ruvaiz Haniffa
Dept. Family Medicine, Faculty of Medicine, University of Kelaniya 25th September 2006

Give sorrow words. The grief that does not speak, whispers the overwrought heart and bids it break Macbeth William Shakespeare English dramatist 1564-1666.
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Bad News: Medical information which is not perceived as good by patients or his/her family. Breaking bad news is one of the most difficult tasks a doctor will face repeatedly during his/her professional life. Doctors trained in the skill of communicating bad news are able to do so in a manner that will improve patient satisfaction and physician discomfort.
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Examples in Family Practice:

1. Informing Pt/Family of treatable life threatening illness. E.g. Diabetes, Hypertension, IHD 2. Informing Pt/Family of treatable illnesses which could have long term consequences.
E.g. Schizophrenics, TB, Dermatological conditions.
3. Informing Pt/Family of terminal illness.E.g.

Cancers
4. Informing family of death of loved one.

The degree as to how bad the news will depend on the context in which it occurs, how it is delivered, the way it will be interpreted, and how the recipients will react to it.
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Principles of Breaking Bad News 1;

1. THE Pt HAS TO BE TOLD THE TRUTH. 2. THE Pt WHO DOES NOT WANT TO KNOW THE TRUTH HAS A RIGHT NOT TO BE TOLD, UNTIL READY. How to decide which principle to follow? DO NOT ANSWER ANY QUESTION THE Pt HAS NOT ASKED.
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Principles of Breaking Bad News 2;

Must get an idea if Pt wants to know or not.
What ideas do you have about your illness Do you know what your illness is The Pt who wants to know may say I suppose its Cancer The Pt who does not want to know may say I hope it is nothing serious
MAY NEED A SERIES OF CONSULTATIONS TO ASSESS Pt WILLINGNESS/READYNESS TO KNOW OR NOT TO KNOW
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Difficulties in Breaking Bad News 1

1. Doctor may feel responsible 2. Doctor may fear blame 3. Worry that it will change the existing Doc-Pt relationship 4. Worry about not having answers to questions that may be asked 5. Worry about doctors personal feelings and reaction to the news 6. Not knowing how to give the news 7. Fear of doing wrong or giving wrong information 8. Fear of Pt reaction to the news.
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Difficulties in Breaking Bad News 2

1. Whether to tell
doctor should know Pt personally, previous reaction to illness, family resources and supports available etc., etc
2. 3. 4. 5.
Whom to tell When to tell What to tell How to tell
Options
1. Full disclosure - Give Pt the full information 2. Non disclosure Information not given 3. Individualized disclosure- Flexible approach
May need several individual and family consultation to decide on Best option. MUST NOT DELAY TOO LONG!
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Methods;
Several. Widely used American Family Physicians recommendation 2001
A. B. C. D. E.
Advanced Preparation. Confirm medical facts and tests, review data, get
second opinion, doctor should prepare emotionally for encounter
Build up therapeutic Doct-Pt relationship. Identify best option of

disclosure, take in to account socio-economical and cultural factors
Communicate well. Maintain eye contact, show concern, show

empathy/sympathy, use Pt language as far as possible, avoid medical jargon, proceed at Pts pace, allow time for expression emotion and silence
Deal with Pt and Family reactions. Encourage and validate emotions. Offer realistic hope and
reassurance when and where available.
DO NOT GIVE BAD NEWS AND WALK AWAY
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Reaction to Bad News;

Well identified process of reaction. But may not occur in given order and may occur in reverse or all at the same time.
1. 2. 3. 4.
Incredulity- Stage of disbelief. Pt thinks doctor has made a mistake and may seek another opinion. Anger- When Pt realizes doctor is right, will get angry with self, find fault with self, family and doctor Acceptance- Accepts the realistic inevitable Despair- May give up all hope and become depressed.
Important to recognize each stage and prepare and guide Pt and Family through it. E.g.- In (1) can arrange for early referral on priority basis In (4) can counsel for depression and if it occurs can treat it
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Care of the Dying Patient 1

Ensure Pt is comfortable as possible mentally, physically and socially. - mentally free of pain - physically remove non essential invasive medical devices - socially Pt may be more comfortable at home rather than hospital Ensure family member are fully aware of the situation, kept informed and are contactable.
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Care of the Dying Patient 2

Ensure adequate privacy if in hospital E.g. In ICU or Ward. Respect religious and cultural beliefs and practices when and where ever possible. - Visit by Priests etc Respect emotions of family members.
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Bereavement Care
Bereavement reaction is a normal process. Person goes through phases of Incredulity, Anger, Acceptance and Despair. The reaction usually lasts up to a maximum of 6 months. If beyond usually need medical attention. Important to give mental, physical and social support in the initial stages. E.g. Early identification of those who do not recover and proper management.
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Current Research;
In the West
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Pt would like doctors to be truthful. Give them caring compassionate care and request for non technical explanation Like to express feels and ask questions doctors say breaking bad news was stressful and the effected lasted long after the encounter.
In Sri Lanka Relatives and not the Pt wanted to be told the truth
When Pt told they reported it as been traumatic but were satisfied with kindness of doctors Doctors reported been worried about how to break bad news and reported feeling depressed after encounter
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Summary
Conveying bad news is part of the duty of a doctor. Do not shy away from it. In doing so must have appropriate attitude and communication skills, must have all facts of the situation and must understand Pt and Family concerns and capabilities News must be conveyed in a caring, sensitive and professional manner so that Pt morale can be maintained to come to terms with the news. Doctors should equip themselves with cognitive and behavioural strategies to cope with personal discomforts of breaking bad news.
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Tell me and I forget, Teach me and I remember, involve me and I learn
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DR Ruvaiz Haniffa: Dept. Family Medicine, Faculty of Medicine, University of Kelaniya 25 September 2006

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Breaking Bad News

Examples in Family Practice:

3. Informing Pt/Family of terminal illness.E.g.

4. Informing family of death of loved one.

Principles of Breaking Bad News 1;

Principles of Breaking Bad News 2;

Difficulties in Breaking Bad News 1

Difficulties in Breaking Bad News 2

Whom to tell When to tell What to tell How to tell

Build up therapeutic Doct-Pt relationship. Identify best option of

Communicate well. Maintain eye contact, show concern, show

DO NOT GIVE BAD NEWS AND WALK AWAY

Reaction to Bad News;

Care of the Dying Patient 1

Care of the Dying Patient 2

Tell me and I forget, Teach me and I remember, involve me and I learn

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