- bad news
‘any news that drastically and negatively alters the patient’s view of her or his future’ (Buckman, 1984). It is only the patient, client or carer who can make the decision about whether news is welcome or ‘bad’.
Despite the difficulties involved with determining and communicating bad news, it should not be considered in isolation from other skills required for patient–professional interactions. The professional needs to build rapport, explore the patient’s ideas and concerns, adopt patient-centred care and be empathic. These strategies are central, too, to breaking bad news.
- patient-centred care
care processes that are structured to benefit the patient.
While every patient is different, there are certain strategies that should be learnt and adopted to help guide any consultation, including consultations that involve breaking bad news. These strategies include preparation, active listening, recognising and responding to emotional cues, and arranging follow-up as appropriate.
- emotional cues
cues that are commonly relayed through the body, by means of facial expressions, gestures, and so forth. Emotional cues may signal enjoyment, fear or distress.
This chapter considers the definition of bad news and uses examples of clinicians breaking bad news to the patient in relation to diagnoses of cancer and sexually transmitted infections. It highlights the importance of how information is given and the necessity of checking understanding. Health professionals also need to consider their own responses and emotions in dealing with difficult consultations, and ensure their own self-care.
Introduction
Communicating about bad news is not solely a task involving the giving of clinical information. It is a complex interaction, which may also comprise some or all of the following components:
- responding to a patient’s and/or family member’s/carer’s emotional cues;
- dealing with the stress caused by a patient’s expectation of cure;
- dealing with the involvement of family members;
- giving hope when the situation is bleak (Baile et al., 2000).
It is also important to be aware of the impact of breaking bad news on the informant (you as the health professional) as well as the recipient. Stress arising from frequent interactions such as these can cause reluctance in health professionals to deliver bad news in case of negative responses they cannot deal with appropriately (Tesser, Rosen & Tesser, 1971). Support from colleagues and debriefing following these difficult consultations are important.
In the past, doctors in particular were prone to be paternalistic and tried to shield their patients from upsetting diagnoses involving life-threatening conditions. The more acceptable approach today is patient- (or client-) centred (Stewart et al., 1995). Patient-centredness encourages health professionals to be collaborative and open with information sharing, and to involve patients and families in care management planning. Such collaboration, openness and involvement are important not just because patients increasingly expect them. They are important also because there is a legal requirement for patients to be given all relevant and appropriate medical information (see Chapter 22). However, the legal dimensions of this communication should not cloud the health professional’s expressions of sensitivity, empathy and compassion.
How to communicate bad news
A useful format for breaking bad news is the six-step approach known as SPIKES (Setting up, Perception, Invitation, Knowledge, Emotions, Strategy and summary; Baile et al., 2000). This is mainly used in the context of cancer diagnosis, with step 6 (‘Strategy and summary’) focusing on treatment options that may be outside the scope of the professional breaking the news. Considering complex tasks as a series of steps in this way is helpful, especially for learners. The protocol is evidence-guided; that is, research has evidenced its benefits (Baile et al., 2000). While SPIKES dates back 15 years, it is still widely used and referenced. We therefore refer to SPIKES here rather than other, comparable models that are also mainly focused on cancer diagnosis, communication and management.
- Arrange privacy and make sure there will be no interruptions.
- Involve significant others as appropriate.
- Sit down.
- Connect with the patient: eye contact, touch.
- Advise the patient of the time you have available.
- Use open-ended questions: ‘What have you been told about your condition so far?’
- Gather information to explore the patient’s perception of the situation.
- Explore ideas, concerns and expectations.
- Correct misinformation as necessary.
- Try to determine whether the patient is in denial.
- Find out how the patient would like to receive the information (this is a useful step at the time of ordering tests, so both doctor and patient are prepared for the ways the results should be communicated).
- Gauge how much information the patient wants.
- Warn the patient that bad news is coming: ‘Unfortunately I’ve got some bad news to tell you.’
- Break information into small chunks.
- Use appropriate language and check for understanding of each chunk of information.
- Look out for the patient’s emotional reaction.
- Identify the emotion (such as anger, sadness and disbelief).
- Identify the reason for the emotion, asking the patient about it if necessary.
- Make an empathic statement to acknowledge the emotion.
- Present treatment options.
- Have shared decision-making.
- Reach consensus.
- Plan follow-up.
- empathic statement
a statement that focuses on (and seeks to alleviate) the emotional state of another person.
Depending on the context the health professional may already know the patient and perhaps have arranged the tests that are going to be discussed. However, this is not always the case in team-based care and it is important to check what the patient already knows, has been told and may be expecting. The patient record may not contain enough details about such important topics.
Below is an example of an initial consultation and then a follow-up interaction between a female patient and a male general practitioner (GP) which involves breaking bad news in relation to a diagnosis of breast cancer. This is a fairly common consultation as the risk of developing breast cancer during a woman’s lifetime in one in eight (AIHW, 2012).1
Shelley Appleton is a 52-year-old woman consulting her GP. After the doctor asks her to sit down she begins by saying: ‘I found a lump in my breast last night while showering and I’d like you to check it for me.’ After asking about her symptoms (the lump is small and painless and in the lower part of the right breast) and family history (her grandmother died of womb cancer), the doctor examines Shelley’s breasts. They then both return to their seats.
DOCTOR: Yes, you have a lump in the right breast. I can’t tell you what it is at the moment. You will need to have a mammogram and possibly an ultrasound to check it out.
Shelley: [Looking anxious] Do you think it is cancer, doctor?
DOCTOR: At your age that is always a possibility, but I wouldn’t worry until you have the tests. There’s really no point in worrying. Have you had a mammogram before?
DOCTOR: Not really. No more than an ordinary X-ray. You should really have had one at 50, you know.
Three days pass.
DOCTOR: Come in, Shelley. I have your test results. It’s not good news.
SHELLEY: The other doctor at the X-ray centre said I should see you straight away. I guessed it is bad.
DOCTOR: Yes, I am afraid it very much looks like you have breast cancer. I will need to refer you to a specialist. Is there anyone you would like me to refer you to? Do you know any of the specialists?
SHELLEY: [Close to tears] It’s our 25th wedding anniversary in five weeks. We’ve booked a holiday in Fiji. Will I still be able to go? What shall I tell Peter? Will I need an operation?
DOCTOR: I really can’t answer any of those questions. You will need to discuss them with the breast specialist.
[Phone rings – doctor answers, says he is busy and asks the caller to ring back later.]
DOCTOR: Let me write you a referral letter. Dr Spencer is a good surgeon.
He turns to the computer and begins typing.
Analysis and reflection
The main failings of the doctor in the above consultation are a lack of empathy and a failure to respond to Mrs Appleton’s cues in relation to her emotional state. The consultation is not wholly bad: the GP asks about Shelley’s symptoms and family history to make an assessment of her risk of having cancer. He also examines her to confirm the presence of a lump. Finally, he makes the right management decision in referring her for diagnostic investigations.
The first part of the consultation seen above does not involve breaking bad news but, given Shelley’s age and presentation, there is a high probability that she will have cancer. The doctor acknowledges her concern about this possibility, so telling her not to worry is unlikely to be reassuring. An empathic statement would have been more helpful – for example, ‘Yes, cancer is a possibility, but I cannot be sure until you have some further tests. It is understandable that the tests and the wait will make you anxious, but it is very good that you have come in as soon as you noticed the lump, and I can get things moving quickly.’
Another issue that arises is whether this doctor indeed knows whether a mammogram is painful or not. His gender makes little difference, as only a proportion of female GPs will have had the test themselves, depending on their age. Still, he will not have had the experience himself, and therefore should not claim to know whether a mammogram is painful or not. If Shelley does indeed find the mammogram uncomfortable, she may be less likely to trust this doctor in the future.
Next the doctor implies that Shelley has been remiss in not having had a screening mammogram at the recommended age of 50 years. This may make Shelley feel guilty, and it may lead her to blame herself in relation to the subsequent positive cancer diagnosis.
The second follow-up consultation focuses on breaking bad news. If we consider the doctor’s performance in relation to the SPIKES protocol, we find there is a lot of room for improvement! Let us analyse the consultation bit by bit.
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