Understanding “breaking bad news”

1. Understanding “breaking bad news” Clare Warnock Practice development sister WPH

2. What is breaking bad news • How would you describe breaking bad news • Who does it • What is bad news

3. What is breaking bad news • Traditional view • the moment when a doctor provides significant information about diagnosis, prognosis or treatment to patients and their families in a one to one consultation • the role of the HCP is to be present • as a witness to what has been said and • providing support once the consultation is over • “Modern view” • A wide range of HCPs are involved in BBN • Other information can be classified as bad news • BBN is a process • There may be multiple episodes of information provision • often “ad hoc” and not part of a pre-planned consultation • It also includes activities that take place before, during and after bad news is given

4. Popular definition • any bad, sad or significant information that negatively alters a person’s expectation or perception of their present or future (Fallowfield and Jenkins 2004) • Key items • ANY information • Individual expectation • Individual perception

5. What do you think could classify as bad news • Examples • informing relatives of a patient’s deterioration or death, • advising a patient that they need to move into a residential home, • explaining the details of arduous treatment such as renal dialysis or chemotherapy, • providing daily updates to family members when a patient’s condition is not improving • explaining transitions in care for example from curative to palliative to end of life • failed discharge plans • Telling someone they can’t drive any more

6. What is bad news – it depends! • the same information could be interpreted as good, bad or neutral by different people • influenced by subjective factors • patient’s expectations, values, life experiences and social situation • the events leading up to and surrounding the moment that the information is given • How might different people react to being told they need to have surgery?

7. Breaking bad news as a process • BBN is not about a single consultation • Dewar’s early work in spinal injury unit • Initial moment • Followed by multiple episodes of potential bad news • Realising the implications of spinal injury over time • It also involves the activities that take place before, during and after bad news is given

8. What activities are carried out around bad news? • Assessing the needs of patients and relatives for further information; recognising their cues and prompts • Working with the patient and family to achieve consensus when there are issues about who should be informed • Identifying and prioritising the patient’s preferences for information • Liaising with the appropriate members of the healthcare team to initiate discussions where the need is identified or requested • Coaching and supporting patients and relatives who find it difficult to ask questions or talk to the doctors

9. Other activities around BBN • Helping patients ask questions when they appear to be confused or reluctant to do so • Supporting others who are providing the information to find alternative words or explanations if the patient appears not to understand or needs clarification • Communicating what has been said in the consultation to the rest of the healthcare team • Eliciting patient and relatives’ feelings about the information they have received • Listening to and acknowledging the emotional reactions of patients and relatives to bad news • Explaining and discussing the information received and its implications

10. Other activities around BBN? • Answering questions as they arise, identifying and clarifying misunderstanding and explaining complex medical terminology • Providing information about the next steps in the care pathway • Helping the patient and relatives make decisions about care • Helping patients and relatives address complex issues e.g. what is meant by DNAR, informed consent, advanced care directives • Supporting patients and relatives when they realise the implications of their situation or the information they have been given • Helping the family reach a consensus when there is disagreement between them about the plan of care • Acting as an intermediary between patients, relatives and the healthcare team

11. Why is BBN important? • Patient preference – research consistently shows • Most patients want to be informed • variations in the depth and level of knowledge desired •  Other potential positive outcomes • building a sense of trust between patients and the healthcare team • enabling patients and relatives to make appropriate decisions and plans based on a realistic insight into their situation

12. What are the negative consequences of not providing patients with bad news?

13. Consequences of not BBN Impact on treatment and decision making • Patients receiving burdensome, inappropriate and unnecessary treatment • False optimism and being unable to marry what is happening with the information received • Misunderstanding and confusion over the intention and aim of treatment • Denying patients the opportunity to participate in decision making • Unnecessary anxiety in worrying about the unknown

14. Impact on end of life care • Depriving patients and families of essential time before the patient’s condition deteriorates • Preventing the discussion of end of life preferences • Denying patients the opportunity to get their affairs in order Impact if relatives informed and the patient isn’t • Feeling isolated and unable to communicate with each other • Unnecessary strain on family relationships • Families carrying the burden of deception

15. Impact on the healthcare team • Job stress and burnout • Poor job and role satisfaction • Disagreement and fractured relationships if not all agree with the information provided

16. Word of caution • Some patients prefer not to receive some or all of the facts as this is how they cope with their illness • Cultural differences • preferences and behaviours around information relating to particular diagnoses, such as cancer, prognosis and end of life decisions • in some cultures it can be common for the family to be given the information while the patient is shielded from the full facts. • Individual patient’s preferences for information should guide the content, timing and delivery of information

17. Does being honest destroy hope? • research reveals that providing honest information does not remove hope • honest information can support patients in their efforts to maintain hope • reduces fear of the unknown • enables patients to match their hopes with the reality of their experience • Is this a contradiction?

18. Reframing hopes and goals(Campbell 2010) • “When we worry about destroying hope we are generally referring to a very specific hope of getting better or living longer. • But hope is a complex, multi-dimensional and above all flexible construct... • One can shift from hoping for a cure...to hoping to go home from the hospital. • Such a shift in the things one hopes for requires a reframing of goals to meet the realities at hand...(a reality) that none of us would wish for”

19. Reframing hopes - examples • Hopes described by patients with a life-limiting illness include: • living longer than expected • good symptom management • getting the most out of the time that is left • making it to certain events or achieving certain goals • mending damaged relationships • spending special time with family and friends • This doesn’t mean people want to be in that situation (or that they won’t be sad/angry/upset) • It is a way of coping that can be used over time

20. Summary – what have we learnt about BBN? • Bad news includes many different types of information • Information is defined as “bad news” by individuals and cannot always be determined in advance • BBN is a process with multiple episodes of information provision • as people experience the implications of their situation and raise questions and concerns • It also includes the activities before, during and after the news is given • HCPs carry out a wide range of diverse roles in relation to BBN

21. Final notes • The way that bad, sad and significant information is given is important • The consequences are long-lasting • How it is done can influence • experiences and satisfaction with treatment • relationships with the healthcare team. • adherence and compliance with treatment • coping with the consequences of illness • Providing information in a way that helps the patient understand and cope with what they are told requires skills and knowledge • Guidelines and good practice advice have been developed to support staff • These will be explored in the next section of the study day