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The breaking of bad news was traditionally regarded to be the time when a doctor and nurse sat down with a patient and family members to provide information about, for example, a life-limiting diagnosis or a poor prognosis. However, breaking bad news is now generally accepted as a process, not a one-off event, and is considered to refer to any bad, sad or difficult information that alters patients’ perceptions of their present and future
Nurses have an important role in the process of providing information and helping patients prepare for, receive, understand and cope with the bad news they have been given.
Within this framework, the role of the nurse is to be present during the consultation to assist both parties, acting as a witness to what has been said and providing support to the recipient of the news once the consultation is over. More recently, this picture of breaking bad news has been challenged by suggestions that it is too simplistic and may not reflect accurately the experience of those receiving or providing the information
What is bad news? • A frequently cited definition of bad news in health care is that it is any bad, sad or significant information that alters negatively people’s expectations or perceptions of their present or future. This definition moves beyond the narrow perspective of diagnosis, prognosis and treatment, which restricts the scope of bad news
a wide range of information can be classified as bad news, including subjects that often lie within the concern of the wider multidisciplinary team.
Examples of types of information that can be classied as bad news • Informing relatives of a patient’s deterioration or death. • Advising patients that they need to move into a residential care home. • Explaining the details of difficult treatments such as renal dialysis or chemotherapy. • Providing daily updates to family members when a patient’s condition is not improving. • Discussing the meaning and implications of transitions in care, such as moving from curative care to palliative care and end of life care.
certain news, such as a diagnosis of terminal illness, is likely to be perceived as bad by most people. However, it may not always be possible to determine in advance how information will be received . For example, informing patients that they are to have an operation could be perceived positively by one person, as it is confirmation of a plan for life-saving or symptom-improving treatment. However, a person who has an overwhelming fear of hospitals or anaesthesia may view the news negatively. Another person could find the news upsetting because the date scheduled for surgery clashes with a valued, planned event such as a family wedding.
However, bad news situations also arose over the course of the patients’ stay as they began to realise the implications of the original news that they had been given. When patients raised questions and concerns about their situation, the staff member who provided explanation and information was then engaged in breaking bad news.
From this wider perspective, the process of breaking bad news can be considered to involve activities that take place before, during and after the initial provision of information
The Ten Elements 1.Describe the news in a clear and straightforward manner. • Do not lie, hide the message, sugarcoat, use jargon, minimize, or downplay. • Do not make promises about the future that may not hold true. • Do not overreact. • Do not avoid adding honest perspective—“Although this is by no means a good situation, it is not as bad as…”
2. Explain why the action is being taken. • What is the logic behind the action? • How does the action support the benefits the patient health? • What was being done wrong? • How will the action help solve the patient health problem?
3. Explain how the decisions and actions that are made will benefit the patient. • If there’s no absolute. But we are waiting for positive results. • The test of “success” is reactions such as, “I don’t like it, and it may be the best for the patient is but I see it the best considering the situation.” • We have done all the possible action we believe is right and all the health team is involved in assuring how the action is going to change the meanwhile situation.”
4. Involve a high-status messenger in delivering the message. • Who sends the message says a lot about how much the whole health team cares about the patient. • The health team (all health team) is involved.
5. Deliver the message in a timely manner. • Reactive communication is usually defensive and apologetic. • Do the patient and families believe that they have enough time to react properly, to share in the decision made, to change their decision if they wanted?
6. Identify who made the decision and what process was used. • Who was involved in the final decision making process? • What decision-making process was followed?
7. Describe the effort that went into the decision. • What actions, procedures, consultations, ..etc were conducted behind the scenes? • How painful, and satisfactory was the process of making the decision?
8. Outline some of the alternatives that were considered. • What other creative and thoughtful ideas were considered? • Why were they not implemented?
9. Show that the health care providers cares about patient. • How the health care providers behaves in communicating bad news shows its “true colors.”
10. Describe what action is required and what, if anything, can be done to change the decision or help avoid the problem in the future. A. To change action: • Output ….must increase to X. B. To avoid the problem in the future: • new direction must be taken. • new findings appeared.
6-Step Protocol • Getting started • What does the patient know? • How much does the patient want to know? • Sharing the information • Responding to patient and family feelings • Planning and follow-up
Step 1: Getting started • Plan what will be discussed. • Confirm the medical facts of the case. Ensure that all the needed information is available. • Create an environment conducive to effective communication. • Ensure privacy and adequate seating. • Allot adequate time for the discussion. Do not slip this into a short interval between other • critical tasks. Prevent interruptions. Arrange to hold telephone calls and pages. • Determine who else the patient would like to have present for the discussion. This might • include family, significant others, surrogate decision makers, and/or key members of the
Step 2: What does the patient know? • Start the discussion by establishing what the patient and family know about the patient’s health. Questions might include: • What do you understand about your illness? • How would you describe your medical situation? • When you first had symptom X, what did you think it might be? • What did Doctor X tell you when he sent you here? • Did you think something serious was going on when…?
Step 3: How much does the patient want to know? • Each person has the right to voluntarily decline to receive any information and may designate someone else to communicate on his or her behalf. Ask the patient and family how they would like to receive information. Possible questions include the following: • If this condition turns out to be something serious, do you want to know? • Would you like me to tell you the full details of your condition?
Step 4: Sharing the information • Deliver the information in a sensitive but straightforward manner. Say it, then stop. • Avoid delivering all of the information in a single, steady monologue. Use simple language • that is easy to understand. Avoid technical jargon or euphemisms. Pause frequently. Check for understanding. Use silence and body language as tools to facilitate the discussion. Do not minimize the severity of the situation. Well-intentioned efforts to • “soften the blow” may lead to vagueness and confusion.
Step 5: Responding to feelings • Patients and families respond to bad news in a variety of ways. Some respond emotionally with tears, anger, sadness, love, anxiety, relief, or other strong emotions. • Others experience denial, blame, guilt, disbelief, fear, or a sense of loss or shame, or may even • intellectualize why the situation is happening. • A few may demonstrate reflexive psychophysiologic responses such as “fight or flight” and may even try to bolt from the room or totally withdraw into themselves. Parents may become very emotional when thinking about actually telling their child the diagnosis.
Ask them to describe their feelings: • I imagine this is difficult news… • You appear to be angry. Can you tell me what you are feeling? • Does this news frighten you? • Tell me more about how you are feeling about what I just said. • What worries you most? • What does this news mean to you?
Step 6: Planning and follow-up • Gather additional information or performing further tests. • Arrange for appropriate referrals. • Explain plans for additional treatment. • Discuss potential sources of emotional and practical support, eg, family, significant others, friends, social worker, • spiritual counselor, peer support group, professional therapist.
