breaking bad news (bhp)

7/18/2019 Breaking Bad News (bhp)

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Breaking Bad News

What Is Bad News?

One source defines bad news as “any news that drastically and negatively alters the patient'sview of her or his future.” Bad news is stereotypically associated with a terminal diagnosis, but

family physicians encounter many situations that involve imparting bad news; for example, a pregnant woman's ultrasound verifies a fetal death, etc.

How a patient responds to bad news can be influenced by the patient's psychosocial

context. t might simply be a diagnosis that comes at an inopportune time, such as unstable

angina re!uiring angioplasty during the wee" of a daughter's wedding, or it may be a diagnosisthat is incompatible with one's employment, such as a coarse tremor developing in a

cardiovascular surgeon. When the physician cares for ultiple ebers of a faily! the lines

between the patient's needs and the faily's needs ay becoe blurred.

Why Is Breaking Bad News "o #ifficult?

#here are many reasons why physicians have difficulty brea"ing bad news. $ common concern is

how the news will affect the patient, and this is often used to %ustify withholding bad news. n

&(), the $merican *edical $ssociation's first code of medical ethics stated, “$he life of a sick

person can be shortened not only by the acts! but also by the words or the anner of a

physician. t is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid

all things which have a tendency to discourage the patient and to depress his spirits.”

+abow and *chee "eenly describe the end result, “-linicians focus often on relieving patients'

bodily pain, less often on their emotional distress, and seldom on their suffering.”

earning general communication s"ills can enable physicians to brea" bad news in a manner that

is less uncomfortable for them and more satisfying for patients and their families. /ollowing

traumatic deaths, surviving family members %udged the most important features of delivering badnews to be the attitude of the person who gave the news! the clarity of the essage! privacy!

and the newsgiver's ability to answer %uestions. $s /ran"s observes, “t is not an isolated s"ill

but a particular for of counication.”

How "hould Bad News Be #elivered?

&&#(&N)* +,*+&,&$I-N• /amiliari0e yourself with the relevant clinical information. deally, have the patient's

chart or pertinent laboratory data on hand during the conversation. Be prepared to

provide at least basic inforation about prognosis and treatment options.

• &rrange for ade%uate tie in a private! cofortable location. nstruct office or

hospital staff that there should be no interruptions. #urn your pager to silent mode or

leave it with a colleague.



• entally rehearse how you will deliver the news. 1ou may wish to practice out loud,

as you would prepare for public spea"ing. 2cript specific words and phrases to use or

avoid. f you have limited experience delivering bad news, consider observing a moreexperienced colleague or role play a variety of scenarios with colleagues before actually

being faced with the situation.

• +repare eotionally.

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• 3etermine the patient's preferences for what and how much they want to "now.

• 4hen possible, have faily ebers or other supportive persons present. #his

should be at the patient's discretion. f bad news is anticipated, as" in advance who theywould li"e present and how they would li"e the others to be involved.

• Introduce yourself to everyone present and as" for names and relationships to the

patient.

• 2oreshadow the bad news, “'m sorry, but have bad news.”

• /se touch where appropriate. 2ome patients or family members will prefer not to be

touched. Be sensitive to cultural differences and personal preference. $void inappropriate

humor or flippant comments; depending on your relationship with the patient, some

discreet humor may be appropriate.

• $ssure the patient you will be available. "chedule follow3up eetings and ma"e

appropriate arrangements with your office. $dvise appropriate staff and colleagues of the

situation.

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&sk what the patient or faily already knows and understands . One source advises,“Before you tell, as"5. /ind out the patient's expectations before you give the

information.”

• "peak frankly but copassionately. $void euphemisms and medical %argon. 6se the

words cancer or death.

• &llow silence and tears, and avoid the urge to tal" to overcome your own discomfort.

roceed at the patient's pace.

• Have the patient tell you his or her understanding of what you have said. 7ncourage

!uestions. $t subse!uent visits, as" the patient if he or she understands, and use repetitionand corrections as needed.

• Be aware that the patient will not retain uch of what is said after the initial bad

news. 4rite things down, use s"etches or diagrams, and repeat "ey information.

• $t the conclusion of each visit, suari4e and ake follow3up plans.

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• &ssess and respond to eotional reactions. Be aware of cognitive coping strategies

8e.g., denial, blame, intellectuali0ation, disbelief, acceptance9. Be attuned to body

language. 4ith subse!uent visits, monitor the patient's emotional status, assessing fordespondency or suicidal ideations.

• Be epathetic; it is appropriate to say “'m sorry” or “ don't "now.” -rying may be

appropriate, but be reflective:are your tears from empathy with your patient or are theya reflection of your own personal issues

• #o not argue with or critici4e colleagues; avoid defensiveness regarding your, or a

colleague's, medical care.

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• -ffer realistic hope. 7ven if a cure is not realistic, offer hope and encouragement about

what options are available. 3iscuss treatment options at the outset, and arrange follow<up

meetings for decision ma"ing.

• *xplore what the news eans to the patient . n!uire about the patient's emotional and

spiritual needs and what support systems they have in place. Offer referrals as needed.

• 6se interdisciplinary services to enhance patient care 8e.g., hospice9, but avoid using

these as a means of disengaging from the relationship.

• $ttend to your own needs during and following the delivery of bad news. ssues of

counter<transference may arise, triggering poorly understood but powerful feelings. $

formal or informal debriefing session with involved house staff, office or hospital

personnel may be appropriate to review the medical management and their feelings.

breaking bad news (bhp)

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