Breaking bad medical news
Delivering bad news is never easy, especially for health care professionals who must tell a patient or a loved one complex medical information. Such a conversation must be a skilled art of striking a fine balance between truth and hope. Presenting properly structured and well-orchestrated communication can have a positive therapeutic effect.
It may be difficult for a health care professional to discuss bad news, but withholding vital information about a diagnosis or prognosis with the presumption that a patient or loved one will not be able to “handle it” may not always be justified. Consider the patient’s autonomy and “right to know” while recognizing the emotional consequences on the recipient’s mental health.
Goals of breaking bad news
Before addressing the patient or loved one, recognize the goals for the situation:
To collect information from the patient in order to develop an idea regarding their existing level of knowledge about the condition and their expectations
To convey information with clarity, keeping in mind what the patient needs and wants
Provide emotional support and assistance as they face the aftermath of the bad news
Minimize loneliness and isolation
To develop a treatment plan, long-term strategy or vital next steps in collaboration with the patient or loved one
There are also common barriers that medical professionals may encounter, including:
Not being sure about the patient’s expectations
Fear of destroying hope for the patient when conditions are truly uncertain
Fear that a patient or loved one may not be adequately capable of dealing with an uncontrollable or incurable disease
Medical professionals might have presented an overoptimistic picture of the patient’s condition in the past, and this announcement may be challenging when it’s now necessary to deliver bad news
Inability to manage the emotional reactions of the patient or loved ones that may result from hearing this news
SPIKES protocol
SPIKES protocol was developed in 2000 as a communication tool for breaking bad news, specifically to patients with cancer. This approach can be helpful for all medical professionals. SPIKES is an acronym for the six phases of sharing information that may upset patients.
Setting: Choose a quiet, private setting, typically an exam or consultation room. Sit at eye level with the patient or loved one and ensure that they are listening attentively. Avoid interruptions by turning off a phone or pagers. Try to refrain from giving results over the phone, but studies have supported this approach as necessary for telehealth. When that is the only option, ask the patient for the best time when they can talk with no other distractions.
Perception: Evaluate what the patient knows about their disease and medical history up to this point. Recap their disease, current condition and previous treatment before explaining test results or a new treatment plan.
Invitation or information: Ask the patient how much and what information they prefer to receive. Some patients want all the details, whereas others just want a summary.
Knowledge: Give the news in small, easily digestible pieces. Consider educational level, socio-cultural background and current emotional state. Use words that fit your patient’s level of comprehension. Present all facts accurately about treatment options, prognosis and costs. Allow the patient or loved one time to process what they have learned before presenting more information. Avoid using medical terminology and jargon that may be misunderstood. Avoid phrases that promote helplessness, such as, “There’s nothing more that we can do.” Respond to the patient’s reactions as they occur.
Empathy: The empathetic response is a four-part process to acknowledge your patient’s emotions, which may be sad, upset or shocked.
Observe their emotions
Identify their emotions
Identify their reason for the emotions.
Give the patient or loved one time to express their feelings
Tell your patient you understand the emotions, such as, “I know this is not the news you were expecting today” or “I can see this information is upsetting to you”
Summarize or strategize: Before discussing a treatment plan or recommendations for the next steps, make sure your patient is ready. They still may be shocked by the news. Give clear and precise information about the available options. Discuss other steps, such as palliative care or hospice referral, if no further treatment options are available. Patients have less anxiety when they know all their options, are involved in decision-making and can have a clear plan. Always ask whether they want clarification on anything else. If there are steps that can be taken together and another meeting is necessary, outline the agenda for that discussion.
Additional insight for breaking bad news
Most physicians, nurses, and other health care workers are handicapped by their insufficient training in breaking bad news. A common mistake is being so focused on the medical information that they forget to recognize the emotional impact of the news on the patient.
Always allow for silence as well as emotional reactions; do not simply talk all the time
Give time for the patient or loved one to process information; do not overload or withhold information
Be sensitive to nonverbal language, including body language
Use simple language and honest communication
Ensure privacy and confidentiality
Listen to what the patient says
Do not assume you know what concerns the patient
Do not make judgmental comments
Never distort the truth
Don’t give false reassurance
It is essential to master an empathic approach rather than simply deliver facts. Recognize that patients and families remember these conversations forever. When they are done well, patients feel supported, and the emotional flood recedes enough for them to begin hearing about their next steps forward.
Sources: National Institutes of Health and National Center for Biotechnology Information