Bad News Flashcards
What factors affect whether news is determined as “bad”? Give some examples where “bad” news is considered “good” news.
Personal circumstances e.g. age, familial obligation
e.g. relief at having a diagnosis, able to be treated/out of pain, carer may feel that burden is lifted
Define bad news. Give some examples.
Any information that drastically alters a patient’s view of their future for the worse
- feeling of no hope
- threat to a person’s mental/physical well-being
- risk of upsetting an established lifestyle
- conveys fewer choices in an individual’s life
e.g. terminal prognosis, disabling condition, traumatic/sudden death, infertility, antenatal testing, intra-uterine death
Outline the GMC guidelines on delivering bad news.
How much information you share will vary depending on individual circumstances; tailor information according to:
- needs, wishes, and priorities of patient
- level of knowledge about/understanding of condition, prognosis, and treatment options
- nature of condition
- complexity of treatment
- nature and level of risk associated with investigation/treatment
MUST answer patient’s questions honestly and as fully as they wish (where practical)
MUST give patients information they want/need about:
- diagnosis/prognosis
- uncertainties about diagnosis/prognosis (including options for further investigations)
- options for treatment/management (inc. option not to treat)
- purpose of proposed investigation/treatment and what it involves
- potential benefits, risks, burdens, and likelihood of success for each option (inc. whether benefits/risks are affected by which organisation/doctor is chosen to provide care)
Give some reasons why it is important to tell patients bad news.
- maintain trust
- reduce uncertainty (know progress of treatment/disease)
- prevent unrealistic expectations
- allow appropriate adjustment (easier to treat patients who know diagnosis)
- promote open communication (reduce anxiety/distress/dissatisfaction)
- prevent negative impacts on doctor-patient relationship, emotional wellbeing, and adjustment/coping with illness
note: disclosure of terminal illness seen in some cultures as harmful/cruel/dangerous (e.g. in some Islamic cultures, the family is told the news and it is up to them how much to disclose to the patient)
Give some reasons why it is difficult to break bad news.
- fear of patient distress/reaction
- blame (“shoot the messenger”)
- fear of showing emotion
Give some examples of blocking behaviours used when breaking bad news.
- telling patients that distress is normal
- changing the subject
- giving information/advice before concerns have been elicited
- focusing only on physical aspects
- asking leading/closed/multiple questions (not giving patient the chance to open up/break down)
- moving on quickly to the next step rather than giving patient time to express their concerns)
What are the key guidelines of the setting when breaking bad news?
- break bad news face to face
- avoid informing relatives first
- ensure privacy and no interruptions (allow enough time; put bleeper outside)
- find out who patient wants present
- introduce yourself & colleagues (ideally no more than 3)
- sit down (eye level) and give eye contact
- remain calm
- no physical barriers e.g. computer
- make tissues available
- listening mode: silence & repetition
What are the key guidelines of patient perception when breaking bad news?
Start consultation with general questions e.g. “What have you been told about all this so far?”
What are the key guidelines of invitation for information when breaking bad news?
Don’t assume patient wants to know everything - ask and if patient declines allow for denial and offer opportunity for further discussion
What are the key guidelines of knowledge when breaking bad news?
Give a warning shot e.g. “I am very sorry to have to tell you this.”
Give information in small chunks so patient has time to consider and ask questions before continuing
Check understanding (ask patient to recap)
Avoid jargon; use clear, simple explanations and avoid medical jargon and euphemisms (incorporate key terms used by patients)
What are the key guidelines of empathy when breaking bad news?
“How are you feeling?”
Acknowledge connection between news and emotion e.g. “This information has obviously come as quite a shock.”, “I can see this news is very upsetting for you.”
Validate/normalise emotions e.g. “It’s not surprising you feel angry.”. “I understand how you can feel this way.”
Listen to patient’s concerns
What are the key guidelines of strategy and summary when breaking bad news?
Summarise the main discussion topics and check understanding again
Discuss strategy & agree on next step
Be optimistic but avoid inappropriate/premature reassurance
Signal closure, but give opportunity to ask questions and offer future availability for questions
If patient is still distressed, ask if they would like a member of the health care team to remain/someone to be contacted/to be left alone
