Delivery of Bad News

Overview

Bad news is broadly defined as any information that may alter a patient’s view of their future. Bad news is typically life-changing information that should be communicated to the patient and family with empathy Empathy An individual’s objective and insightful awareness of the feelings and behavior of another person. It should be distinguished from sympathy, which is usually nonobjective and noncritical. It includes caring, which is the demonstration of an awareness of and a concern for the good of others. Psychotherapy and honesty.

Effects on patient and families

• Changed vision Vision Ophthalmic Exam of the future; need to alter established lifestyle
• Social stigma and/or impact of the particular diagnosis or treatment
• Lack of hope
• Perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment of decreased options in life
• Financial/practical concerns regarding new diagnosis or treatment

Difficulties for physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship

• Worry about effects of the news on the patient (e.g., depression)
• Fear of the patient’s reaction; uncertainty about how to handle the patient’s emotional response
• Fear of being blamed or challenged
• Fear of not having “all the answers”
• The interaction may cause stress that affects interactions with other patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, colleagues, or their own family

Most common types of bad news

• New diagnosis:
  • Chronic disease (e.g., diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus mellitus)
  • Progressive illness (e.g., multiple sclerosis Sclerosis A pathological process consisting of hardening or fibrosis of an anatomical structure, often a vessel or a nerve. Wilms Tumor)
  • Fatal disease (e.g., Huntington disease Huntington disease Huntington disease (HD) is a progressive neurodegenerative disorder with an autosomal dominant mode of inheritance and poor prognosis. It is caused by cytosine-adenine-guanine (CAG) trinucleotide repeats in the huntingtin gene (HTT). The most common clinical presentation in adulthood is a movement disorder known as chorea: abrupt, involuntary movements of the face, trunk, and limbs. Huntington Disease)
  • Disease impacting fertility (e.g., premature Premature Childbirth before 37 weeks of pregnancy (259 days from the first day of the mother’s last menstrual period, or 245 days after fertilization). Necrotizing Enterocolitis ovarian insufficiency)
• Scope of injury (e.g., season-ending knee injury)
• Disease recurrence or progression despite treatment (e.g., cancer)
• Critical condition or death of a family member

Setting and timing

• Quiet and private setting; never with other patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship or in a place where one can be overheard.
• An adequate amount of time must be allocated for discussion. Do not rush RUSH Abdominal and cardiac evaluation with sonography in shock (ACES) and rapid ultrasound for shock and hypotension (RUSH) are point-of-care ultrasound (POCUS) examinations indicated in cases of nontraumatic, undifferentiated hypotension, or shock. ACES and RUSH: Resuscitation Ultrasound Protocols the encounter. 
• A relative, clergy person, psychologist, and/or social worker may be present to support the patient.

General content and manner of delivery

• All relevant information regarding diagnosis, prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas, alternative treatments, and complications should be discussed with the patient:
  • Never lie to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship!
  • The amount of information should be reasonable.
  • The amount of information patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship want to receive varies by culture, education level, age, and sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria (e.g., studies indicate that younger, female, and more highly educated patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship tend to prefer more detailed information).
• News should be delivered in a sensitive, patient, empathetic, and professional manner.
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship should be given information about where to find support after the discussion ends:
  • Informational pamphlets, websites, or other resources
  • Support groups or hotlines
  • Easy ways to contact someone for questions/concerns that arise after the discussion
• The patient needs to be allowed to process the information at their own pace. 
• The clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship must be aware of proper wording and their own body language.
• The clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship must be attentive to the patient’s verbal and nonverbal responses to know when it’s appropriate to pause.

Protocols for Delivering Bad News

Overview

No one model or method is perfect, though each protocol provides a loose structure for delivering bad news in an effective, compassionate way.  Mnemonics are used for 3 of the most common protocols, though they share many of the same concepts (which are detailed in the subsequent subsections):

• SPIKES protocol:
  • Setting
  • Perception
  • Invitation
  • Knowledge
  • Emotions
  • Summary and Strategy
• ABCDE protocol
  • Advanced preparation
  • Build a therapeutic environment/relationship
  • Communicate well
  • Deal with patient and family reactions
  • Encourage and validate emotions
• BREAKS protocol:
  • Background
  • Rapport
  • Explore
  • Announce
  • Kindle 
  • Summarize

Concept: advanced preparation/background

• Know the patient’s clinical history and background.
• Mentally rehearse and emotionally prepare for the interaction.

Concept: setting/therapeutic environment/rapport

• Delivery of bad news should always be in person, if possible.
• Accompanied by family members, as the patient desires
• Obtain consent to deliver the information in front of other people (e.g., “We are going to talk about something very sensitive. Do you want them to be present?”).
• Private and separate room:
  • Tissues available
  • Seating for everyone
• Avoid interruptions (e.g., silence pagers).
• The clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship should keep a tranquil demeanor.
• Management of body language:
  • Focus on the patient.
  • Maintain appropriate eye contact (avoid charting during discussion).
  • Nonverbal indicators of interest in the patient

Concept: perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment/explore

• Assess the patient’s understanding of the situation.
• Use open-ended questions to gauge the patient’s understanding.
• Correct misinformation and misunderstandings.
• Identify wishful thinking, unrealistic expectations, or denial Denial Refusal to admit the truth or reality of a situation or experience. Defense Mechanisms. 
• Pay attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment to the patient’s answers: The patient will communicate, in one way or another, emotional content associated to their current state (e.g., hope, despair, indifference).

Concept: invitation

• Ask the patient how much detail they desire to know.
  • Do they prefer to know all the details or to focus on the most important result?
  • A competent patient has the right to not know every detail; in these cases, the invitation for more information must be made clear to the patient/family.
• Ask permission to give results:
  • Lets the patient control the conversation
  • For example, “Would it be okay if I review your biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma results now?”
  • Patient may prefer to have family/support person present, so may prefer to wait to receive results (and this wish should be respected).

Concept: knowledge/communicate/announce

• Summarize events in a clear, stepwise fashion.
• Stop often to confirm understanding.
• Avoid technical language or jargon.
  • Use plain, simple language in the patient’s native language.
  • Use a professional medical interpreter when necessary; do not deliver bad news through an interpreting family member.
• Reinforce important key points.
• Answer every question.
• Alignment: Explain the information in a way that aligns the patient’s understanding with reality.

Concepts: emotions/reactions/kindle

• Address emotions as they arise.
  • Look for adaptive and/or maladaptive emotions:
    • Humor Humor Defense Mechanisms/guilt
    • Sadness/despair
    • Realistic hope/unrealistic hope
  • Try to identify why patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship are experiencing the emotions they are feeling.
• Use empathetic statements to recognize the patient’s emotion.
• Validate patient responses; reassure patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship that their opinions are being heard and will be respected.
• Ask open-ended questions to clarify emotions when they are not obvious.
• Ask about emotional and spiritual needs and support systems (the clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship should not shy away from asking about religion). 
• Offer realistic hope without setting false expectations.
  • Excessive reassurance Reassurance Clinician–Patient Relationship may create false expectations.
  • Identify and reinforce coping strategies.
• Be aware of your own wellness during and after delivery of bad news. 
• It is okay to show your own emotions. 
• Never criticize other colleagues and do not become defensive about your or the colleague’s medical care Medical care Conflict of Interest.

Concepts: strategy/summary

• Summarize the important points.
• Set a clear plan for the patient’s next steps, which may include referrals, additional testing, and treatment options.
• Provide patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with contact information in case additional questions arise.
• Provide the patient with support resources, for example:
  • Support group
  • Educational websites
  • Contact hospital religious services if available/desired

Summary of different protocols for delivering bad news