Patient Education and Counseling 41 (2000) 157–160www.elsevier.com/ locate /pateducou

Breaking bad news and personality assessment

a , b b*A. Rudnick , Y. Ezra , E. MelamedaDepartment of Behavioral Sciences at Tel Aviv University Medical School, Israel and Whitby Mental Health Centre, 700 Gordon St,

Whitby, Ontario L1N 5S9, CanadabDepartment of Neurology at Rabin Medical Center, Petah Tiqwa 49100, Israel

Received 1 March 1999; received in revised form 8 September 1999; accepted 4 October 1999

Abstract

Breaking bad news to seriously ill patients is an especially difficult and important part of patient education and counseling.Guidelines for breaking bad news have been previously presented, but this is the first report to address the personality of thepatient in deciding how to break bad news. A case study of a patient diagnosed with amytrophic lateral sclerosis is presented.A psychiatric consultation assisted in assessing the patient’s personality and thus preparing the medical staff for breaking thebad news to him. The patient was assessed as having an obsessive–compulsive personality, and consequently the staff wasinstructed to concentrate on facts and not on feelings when breaking the bad news to him. The patient coped adaptively withthis procedure, as did the staff. This case report illustrates that personality assessment may be of benefit in breaking badnews to seriously ill patients. It remains to be seen whether this procedure can be successfully generalized to other patientsand settings as well as to other domains of patient education and counseling, and if so — whether this will also prove to becost-effective. 2000 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Breaking bad news; Personality; Assessment

1. Introduction avoided telling non-curable patients of their diag-nosis or prognosis in countries such as England [1]

Breaking bad news to patients, i.e., notifying them and France [2]. This is possibly the reason why littlethat they have a grave medical condition, seems to attention has been directed to the systematic studybe a special and important case of patient education and practice of breaking bad news and to ways ofand counseling in that it is usually preliminary and improving it, as made evident by a recent literaturenecessary. The act of breaking bad news is emotion- review which states that it is not even knownally difficult both for the patient and for the physi- whether any approach to breaking bad news in-cian, so much so that even recently, many physicians fluences patient adjustment [3]. Thus, although the

issue of breaking bad news seems most pertinent toconsultation liaison (C-L) psychiatry, a recent C-L*Corresponding author. Tel.: 1 1-905-668-5881; fax: 1 1-905-

430-4032. bibliography compilation does not mention it [4].

0738-3991/00/$ – see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved.PI I : S0738-3991( 99 )00106-8

158 A. Rudnick et al. / Patient Education and Counseling 41 (2000) 157 –160

Recently, some attempt has been made to deal management of the patient, were pained and at a losswith this matter, and consensus guidelines have been as to how to break the (very) bad news to thisformulated [5]. Endorsing an individualized disclo- patient, who was obviously at the prime of his life.sure approach, which aims to match the form and An attending psychiatrist interviewed the patient, andcontent of breaking bad news to the different capaci- established that he had no major psychopathologyties and needs of different patients, these guidelines (according to accepted classificatory criteria [6,7])offer a series of recommended steps for breaking bad and that he had conspicuous obsessive–compulsivenews. Yet, although one of the recommendations personality features, which implies an excessive needoffered is that the physician be sensitive to the of control as a defence against anxiety. This wasperson’s culture, race, religious beliefs, socioeco- manifested by his admitted love of routine, hisnomic class and social background, consideration of emotional constriction and an intellectualized attitudethe patient’s personality is conspicuously absent. to his present illness — expressing interest in minuteThis is consistent with the fact that no psychiatrists details — and to past stresses, as when he comfortedor psychologists — probably best trained at assessing himself during the bombardments of the gulf warpersonality features, although not uniquely so — with the belief that probability calculations, such aswere present on the consensus panel. Moreover, the law of large numbers, protect him (this is not tomerely asking the patients whether they would like say that such a patient does not have a variety ofto know all of the information was considered to be a strong feelings towards such experiences, but rathermore effective and potentially accurate method than that he is less aware of them than others due to hismaking a clinical judgment concerning the needs and attempts to blunt the pain of his anxiety). Hecapacities of patients in regard to breaking bad news requested to be informed of his diagnosis without histo them. This is a psychologically-naive approach, family being present, as he found their anxiety andwhich may be less effective and more harmful than a worry difficult to cope with.psychologically-informed approach grounded in per- Following the psychiatrist’s recommendations, thesonality assessment. We report a case in which resident neurologist directly responsible for manage-breaking bad news to a patient was instructed by ment of the patient gave him clear, detailed andassessment of his personality, and discuss the pros comprehensive information about his diagnosis in aand cons of such an approach, as a possible test-case sympathetic but unemotional and matter-of-fact man-in patient education and counseling (an extensive ner, meticulously responding to the patient’s manyliterature review is not attempted, as this was con- and repeated questions, and all this in one session,ducted recently in some of the above-mentioned thus satisfying the patient’s need for control — if notreferences). control of the disease, than at least control of the

situation of breaking the bad news to him. Help withinforming his wife was offered to him, which he

2. Case report predictably turned down. Throughout the meeting hewas inquisitive, rejected suggestions for emotional

A 42-year-old medical malpractice defence support and remained largely composed, except for alawyer, married with two children (and a pregnant moment of tearful silence. Following that meeting,wife), was admitted to the neurology department for and until his discharge a day later, he continued withinvestigation of progressive right hand paresis. While his daily routine on the ward (reading, eating and thecervical spine and brain MRI were normal, EMG like). Although individual and family support wereshowed signs of upper and lower motor neuron again offered to him, he maintained his choice ofdisease, consistent with clinically observed right ‘pure’ neurological follow-up. The resident neuro-hand hyper-reflexia and fasciculations. Malignancy logist and other medical staff expressed satisfactiontests were negative, and amyotrophic lateral sclerosis about the way breaking the bad news to the patient(ALS) was diagnosed. The department staff, includ- was conducted. At 3 months follow-up, the patienting the resident neurologist directly responsible for was slightly weaker physically, was still working and

A. Rudnick et al. / Patient Education and Counseling 41 (2000) 157 –160 159

had started arranging his will after having shared the which are in many other respects very different onebad news with his family. from the other. One study addressed the impact of

personality types on coping with medical illness [9],which is related to (coping with) breaking bad newsyet wider in scope. We have found no study relating

3. Discussion breaking bad news to personality types. Thus, itseems worthwhile to study different varieties of

This case report illustrates how personality assess- breaking bad news in relation to different personalityment can contribute to the matter of breaking bad types, and to incorporate the teachings of personalitynews. The patient’s personality was assessed as theory into the formulation of guidelines concerningobsessive–compulsive. Thus, an effort was made to breaking bad news. This may also be true of patientinform him of his grave condition in a manner that education and counseling in general.would maintain his sense of control, consistent with It appears that this psychologically-informed ap-his regular coping style. As a result, it seems that the proach may also be of benefit for the medical staff,patient was not overwhelmed by the news and could as it provides means for evaluation and interventionprocess them in his own habitual way. Other per- concerning the problem of breaking bad news, andsonality styles may require other ways of breaking thus a sense of professional (yet humane) controlbad news. Thus, it seems best to break bad news to over this difficult situation. Future study shouldmany dependent persons in the presence of their attempt to elaborate on such means for assessment,families, unlike the isolated way which may be best holding in mind practical considerations such asfor many schizoids and obsessive–compulsives such feasibility in general and cost effectiveness in par-as the patient reported above. Unlike such obses- ticular [10] and keeping it as simple and user-sive–compulsives, avoidant persons may require, at friendly as possible, so that the managing physicianleast initially, a depiction of the bad news – of their himself and possibly all health professionals maydiagnosis and especially of their prognosis – in quite incorporate the insights of personality theory into thegeneral terms, with as little specific detail as possible practice of breaking bad news.(medico-legally and otherwise), lest they be over-whelmed by a confrontation with reality which is toodirect and immediate for their habitual way of

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