BBN

PLAB II-UKMLA CAPSULES

Conquer All 16, Score a Perfect 12!
Breaking Bad News
 1. Post – Operative Bleeding – Aorto-Femoral Bypass Graft - Transferred To Theatre & Blood
Transfused
 2. Intracerebral Bleed – Terminal – Talk to wife/Son
 3. Intraductal Carcinoma In Situ – Early Stage - Breast Cancer
 4. X-ray Lytic Lesion - Osteosarcoma
 5. Post- SOL Operation Ischemic Stroke – Waiting Review By Specialist - Talk to his Son/Wife
 6. Stroke Patient - End Of Life Treatment
 7. Bilateral Ischemic Stroke – Palliative Care – Talk to Daughter
 8. Terminal Stage Dementia – Palliative Care – Talk to Daughter
 9. Road Traffic Accident In a Child - Extradural Hematoma/Pelvic Fracture - Taken to Theatre
Breaking Bad News Approach
Setting
➢ Grips: If they asked about the patient’s condition from the start: Well, I understand that you are worried & I am really sorry, but
could I just check a few details first?
➢ Are you on your own today? Is there anyone you want to be with you today? 1st shot

Perception
➢ If they asked again about patient’s condition: Unfortunately, he is not doing very well at the moment, but we are taking care of him
as much as we could.
➢ So, I just would like to ask you a few questions to be in a better place to explain to you his/her condition/results.
➢ MAM: What do you know about his/her condition so far ? So, could you tell me how was he/she doing? what kind of symptoms did
he/she have? Did he/she have any medical conditions? Any regular Medications? Any allergies? Any family history? Was there any
complications after that?
➢ Psychosocial: So, Do you have anyone around to support you?
➢ ICE: Do you have any Idea what might be going on with him? Do you have any concerns at the moment?

Invitation
➢ Has anyone explained the results of his/her tests/condition to you? Are you ready for us to discuss his/her test results/condition
today? OR Are you ok to go ahead? 2nd shot
Breaking Bad News Approach Cont’d
Narrative Approach
➢ So, Mr. XYZ has done …. And he was doing well. But then we found …..I am afraid I don’t have good news for you today. 3rd shot

➢ I am really sorry to tell you that he…. (BREAK THE NEWS) then PAUSE – GIVE TIME TO VENT.

Emotions
➢ I can see that made you very upset. Actually, most people would feel that way.
➢ I Know you weren’t expecting this at all & I Know this came as a shock to you.
➢ I am really sorry this has happened. I can understand how difficult and tough this is on you.

Strategy
➢ So, Lets discuss what needs to be done now. OR So would you like me to tell you what we can do in order to move the situation
forward.
➢ Would you like me to call anyone for you?
➢ You can now wait in the waiting area if you’d like, and I will come and update you regularly if there is any changes.
➢ Is there anything else we can do for you today? Anything else you would want to discuss.
Breaking Bad News Approach Cont’d
➢ In Palliative stations:
➢ Management: So, Mr. xyz is now unconscious as you know but he is breathing on his own. And all the specialists discussed his
condition many times and they came to the conclusion that the only way to help him at the moment is with palliative care. Do
you know what palliative care is?
➢ Well, so palliative care is a way where we try to make sure that he is having a good quality of life and that he is feeling as
comfortable as possible. Its actually a kind of a wholistic approach where we take care not only of the patients but of their
relatives, like you as well. So, we will also be supporting you through this tough time.
➢ So, Do you have any concerns at the moment?
➢ Q. Why Palliative? Actually, any kind of active treatment at the moment will not be beneficial for him at all but it also might
put more harm or remorse on him.
➢ Q. Are you giving up on him? Am sorry that you are feeling that way, but we are not giving up on Mr. XYZ at all. Actually, we do
what’s is in his best interest.
Breaking Bad News Stations
1- Aorto-femoral bypass Surgery
Breaking Bad News Stations
1- Aorto-femoral bypass Surgery

Setting
➢ Grips Well, I understand that you are worried & I am really sorry for that, but could I just check a few details first?
➢ Are you here on your own today? Is there anyone you would like to be with you today? 1st shot

Perception
➢ If she asked: Unfortunately, he is not doing very well at the moment, but we are taking care of him as much as we could. So, I
understand that your husband came to the hospital today to have an aorto-femoral bypass operation done. Is that right? So, I
just would like to ask you a few questions to be in a better place to explain to you his current condition. Would that be okay?
➢ MAM + RF: Alright, so what do you know about his condition so far? So, could you tell me how was he doing before the
surgery? what kind of symptoms did he have? Did he have any medical conditions especially blood disorders? Any regular
Medications especially blood thinners? Any allergies? Any one in the family with a blood disorder?
➢ Psychosocial: So, who is usually taking care of him? That’s so good of you. It seems that you are a caring wife. So, Do you have
anyone around to support you? And do you both have any children?
➢ ICE: Do you have any Idea what might be going on with him? Do you have any concerns at the moment? So, Has anyone
explained his condition to you so far? Did anyone explain to you what kind of complications could occur during the operation?

Invitation
➢ Alright, so are you ready for us to discuss his condition today? Are you ok to go ahead?/ shall I proceed? 2nd shot
Breaking Bad News
1- Aorto-femoral bypass Surgery – Cont’d

Knowledge
➢ Narrative Approach: So, Mr. XYZ has had an aorto-femoral bypass operation and as you know this is a big operation since we had
to connect the femoral artery to the aorta which is the biggest artery in the body and therefore it carries some risks. One of those
risks is bleeding after the operation. The operation went well, and he was taken to the recovery room. But unfortunately, while he
was in the recovery room, he was noticed to be bleeding into the drain. So, I am afraid I don’t have good news for you. 3rd shot
➢ I am really sorry to tell you that he has suffered a major bleed and we had to transfuse 6 units of blood. I am afraid your husband
is in a serious condition that we had to take him back to theatre to have another operation in an attempt to stop the bleeding.
PAUSE – GIVE TIME TO VENT

Emotions
➢ I am extremely sorry for delivering this news to you. Can you tell me more about how you feel?
➢ I can see that made you very upset. Actually, most of the people would feel that way.
➢ I Know you weren’t expecting this at all. #I Know that this came as a shock to you.
➢ When she says I don’t know how to …. Answer by ‘Tell me more please about that’ I am really sorry this has happened. I can
understand how difficult and tough this is on you.
Breaking Bad News
1- Aorto-femoral bypass Surgery – Cont’d

Strategy
➢ So, Do you have any concern at the moment?
➢ Q. Is he going to die? Ans: I am really sorry that you are feeling that way, but we are hopeful that the surgeons will be able to
stop the bleed and that he recovers from this.
➢ Q. You made a mistake! Ans: I am not aware of any mistakes during the operation, unfortunately, this is one of the
complications of this operation.
➢ Q. Call his son/daughter? Ans: At the moment I would advise to call them so that they’ll be around in such a situation. Do you
need any help informing your daughters?
➢ Q. I might not see him again. Ans: I can see that you are very worried, and I can understand how difficult and tough this is on
you, but we are doing our best and hopefully, they will be able to stop the bleed.
➢ So, do you have any other concerns? Alright, so for now you can wait in the waiting room if you’d like, and I will come and
update you after the operation or if there is any changes. Is there anything else I can do for you? Anything else you want to
discuss?
Breaking Bad News
2. Intracerebral Bleed – Terminal – Talk to wife/Son
Setting
➢ Grips I am sorry but could I just check a few details first? Are you here on your own today? Is there anyone you would like to be
with you today? 1st shot

Perception
➢ If she asked: Unfortunately, he is not doing very well at the moment but we are taking care of him as much as we could. So I
understand that your husband has been brought to the hospital by the ambulance after collapsing at home. Is that right? So I just
would like to ask you a few questions to be in a better place to explain to you his current condition. Would that be okay?
➢ MAM + RF: Alright, so what do you know about his condition so far? So could you tell me how was he doing before the collapse?
what kind of symptoms did he have? Did he have any medical conditions like high blood pressure, kidney problems, or any blood
disorders? Any regular Medications like blood thinners? Any allergies? Any one in the family with a blood disorder or kidney
disease?
➢ Psychosocial: So, Do you have anyone around to support you? And do you both have any children?
➢ ICE: Do you have any Idea what might be going on with him? Do you have any concerns at the moment? So Has anyone updated
you on his condition so far?

Invitation
➢ Alright, so are you ready for us to discuss his condition today? Are you ok to go ahead?/so shall I proceed? 2nd shot
Breaking Bad News
2. Intracerebral Bleed – Terminal – Talk to wife/Son – Cont’d
Knowledge
➢ Narrative Approach: So actually, we have received Mr. Ali when he came by the ambulance, and we started assessing his
condition right away, we examined him, and we have done a Ct scan on his head which is an advanced scan and it showed that
he collapsed due to a bleed in his brain. I am afraid his condition looks more serious than we thought, and I am afraid I don’t
have good news for you. 3rd shot
➢ I am really sorry to tell you that he has suffered a massive bleed in his brain and that there is very little we can do about it in
terms of removing the bleed out of his brain, unfortunately its not possible to perform an operation. I am so sorry to tell you that
the damage to his brain is so much that it is difficult to say whether he will regain his conscious again or not. PAUSE – GIVE TIME
TO VENT

Emotions
➢ I am extremely sorry for delivering this news to you. Can you tell me more about how you feel?
➢ I can see that made you very upset. Actually, most of the people would feel that way. I Know you weren’t expecting this at all.
➢ I Know this came as a shock to you.
➢ When she says I don’t know how to …. Answer by ‘Tell me more please about that’ I am really sorry this has happened. I can
understand how difficult and tough this is on you.
Breaking Bad News
2. Intracerebral Bleed – Terminal – Talk to wife/Son – Cont’d

Strategy
➢ Management: So, Mr. Ali is now unconscious as you know but he is breathing on his own. And all the specialists discussed his
condition many times and they came to the conclusion that the only way to help him at the moment is with palliative care. Do
you know what palliative care is? Well, so palliative care is a way where we try to make sure that he is having a good quality of
life and that he is feeling as comfortable as possible. Its actually a kind of a wholistic approach where we take care not only of
the patients but of their relatives, like you as well. So, we will also be supporting you through this tough time.
➢ So, Do you have any concerns at the moment?
➢ Q. Why Palliative? Actually, any kind of active treatment at the moment will not be beneficial for him at all but it also might put
more harm or remorse on him.
➢ Q. Are you giving up on him? Ans: Am sorry that you are feeling that way, but we are not giving up on Mr. Ali at all. Actually, we
do what’s is in his best interest.
➢ Q. Why him? Ans: Actually, you’ve told me that he is having high blood pressure, I know he was fine taking his regular
medications, however, sometimes the blood might run very fast in his blood vessels and actually there was a sac in his brain
which might have burst or leaked out blood. This is the explanation we have found. I am extremely sorry for what happened.
➢ Q. Is he going to die? Ans: I am really sorry that you are feeling that way but unfortunately, we do not expect any kind of
recovery from Mr Ali’s condition. Unfortunately, yes he is, am so sorry to tell you that.
➢ Q. Call his son/daughter? Ans: At the moment I would advise to call them so that they’ll be around in such a situation. Do you
need any help informing your daughters?
Breaking Bad News
2. Intracerebral Bleed – Terminal – Talk to wife/Son – Cont’d

➢ Q. I might not see him again. Ans: I can see that you are very worried, and I can understand how difficult and tough
this is on you but we are doing our best and hopefully, they will be able to stop the bleed.
➢ So, do you have any other concerns? OK, I would just leave you my name again, and if any questions rise up just let
me know. Alright, so for now you can wait in the waiting room if you’d like, and I will come and update you after the
operation or if there is any changes. Is there anything else we can do for you? Anything else you want to discuss
Breaking Bad News
3. Intraductal Carcinoma In Situ – Early Stage - Breast Cancer

Setting
➢ Grips Are you here on your own today? Is there anyone you would like to be with you today? 1st shot

Perception
➢ So, I understand that you’ve had a biopsy of the breast done and that you’re here for the results. Is that right? So, has anyone
explained it to you yet? Alright so I am going to explain it to you but before that could I just ask you a few questions to be in a
better place to explain to you the results?
➢ MAM + RF: Alright, So what made do these tests in the first place? Did you have any symptoms? And what did the doctors tell
you? Was there any bumps or lumps in your breast? Any weight loss? When was your first period? Do you have any children? Do
you use any contraceptive method? Do you have any medical conditions? Any regular Medications? Any allergies? Any one in your
family with a history of ovarian or breast cancer? Smoking ?
➢ Psychosocial: So, Do you have anyone around to support you?
➢ ICE: Do you have any Idea what might be going on with you? Do you have any concerns at the moment?

Invitation
➢ Alright, so are you ready for us to discuss your results today? Are you ok to go ahead?/so shall I proceed? 2nd shot
Breaking Bad News
3. Intraductal Carcinoma In Situ – Early Stage - Breast Cancer – Cont’d
Knowledge
➢ Narrative Approach: So actually, you had a mammography done and the specialist told you that its not completely normal. And for this
reason, you had a biopsy done. So, I am afraid I don’t have good news for you. 3rd shot
➢ I am really sorry to tell you that the biopsy shows that you have cancer of the breast. PAUSE – GIVE TIME TO VENT

Emotions
➢ I am extremely sorry for delivering this news to you.
➢ Can you tell me more about how you feel? I can see that made you very upset. Actually, most of the people would feel that way.
➢ I Know you weren’t expecting this at all. I Know this came as a shock to you.
➢ When she says I don’t know how to …. Answer by ‘Tell me more please about that’ I am really sorry this has happened. I can
understand how difficult and tough this is on you.

Strategy
➢ Management: Would you like me to tell you what we can do to move the situation forward? I will refer you to the breast surgeon as
soon as possible within the next 2 weeks, so expect to receive an appointment letter anytime from now. The Specialist is going to
assess your condition further and do further tests and imaging like chest Xray and MRI scan to make sure that the cancer is still in its
early stage. After that you will be started on treatment & the options will be either to remove the breast which we call mastectomy or
part of it by wide local excision. Usually after the surgery you will be started on a kind of treatment known as radiotherapy. Let me
assure you that this is an early stage and there is a good chance for it to be totally cured. Would you like me to explain to you the
cosmetic options in case the whole breast is removed? So, there is an option to have a cosmetic surgery and that is to have breast
implants or breast reconstruction surgery. Is there anything else I can do for you? Anything else you want to discuss?
Breaking Bad News
4. X-ray Lytic Lesion - Osteosarcoma

Setting
➢ Grips Are you here on your own today? Is there anyone you would like to be with you today? 1st shot

Perception
➢ So, I understand that you’ve had some blood tests and an X-ray done and that you’re here for the results. Is that right? So, has anyone explained
it to you yet? Alright so I am going to explain it to you but before that could I just ask you a few questions to be in a better place to explain to you
the results?
➢ MAM + RF: Alright, So what made do these tests in the first place? Apart from the bone pain did you have any other symptoms? And what did the
doctors tell you? Was there any bumps or lumps anywhere in your body? Any weight loss? Do you have any medical conditions? Any regular
Medications? Any allergies? Is there any one in your family with a history of cancer? Smoking ?
➢ Psychosocial: So, Do you have anyone around to support you?
➢ ICE: Do you have any Idea what might be going on with you? Do you have any concerns at the moment?

Invitation
➢ Alright, so are you ready for us to discuss your results today? Are you ok to go ahead?/so shall I proceed? 2nd shot
Breaking Bad News
4. X-ray Lytic Lesion – Osteosarcoma – Cont’d
Knowledge
➢ Narrative Approach: So actually, you have been having bone pain in your legs for over a month and for that you had an X-ray done. I am afraid
the X-ray doesn’t have good news for you today. 3rd shot
➢ I am really sorry to tell you that your X-ray is showing some lesions that are suggestive of osteosarcoma, and am afraid osteosarcoma is a type of
bone cancer. PAUSE – GIVE TIME TO VENT

Emotions
➢ I am extremely sorry for delivering this news to you.
➢ I can see that made you very upset. Actually, most of the people would feel that way.
➢ I Know you weren’t expecting this at all. I Know this came as a shock to you.
➢ I can understand how difficult and tough this is on you.

Strategy
➢ Management: Would you like me to tell you what we can do to move the situation forward? Well, I will refer you immediately to the bone tumor
specialist where he will further reassess you and do further tests and imaging like an MRI scan, and he might need to take a sample of the
swelling as well. Once it is confirmed, the treatment options will be either starting you on a chemotherapy, treating it with radiation or by surgery.
And let me assure you that it usually improves with treatment, however it might need long life monitoring. So, Do you have any concerns at the
moment?
➢ Is there anything else I can do for you? Anything else you want to discuss?
Breaking Bad News
BBN – Post operative ischemic stroke
Setting
➢ Grips I am sorry, but could I just check a few details first? Are you here on your own today? Is there anyone you would like to be with you today?
1st shot

Perception
➢ If she asked: Unfortunately, she is not doing very well at the moment, but we are taking care of her as much as we could. So I understand that
your mum has been scheduled for a brain operation today. Is that right? So, I just would like to ask you a few questions to be in a better place to
explain to you her current condition. Would that be okay?
➢ MAM + RF: Alright, so what do you know about her condition so far? So could you tell me how was she doing before the operation? what kind of
symptoms did she have? Any weakness in her body? Any difficulties in speaking? Did she have any medical conditions like high blood pressure, or
any blood disorders? Any regular Medications like blood thinners? Any allergies? Any one in the family with a blood disorder?
➢ Psychosocial: So, are you the next of kin? So, Do you have anyone around to support you?
➢ ICE: Do you have any Idea what might be going on with him? Do you have any concerns at the moment? So, Has anyone updated you on his
condition so far?

Invitation
➢ Alright, so are you ready for us to discuss his condition today? Are you ok to go ahead?/so shall I proceed? 2nd shot
Breaking Bad News
BBN – Post operative ischemic stroke – Cont’d

Knowledge
➢ Narrative Approach: So as you know Mrs. Gemma has had a brain operation done to remove a tumor and as you know this is a big operation and
therefore it carries some risks. One of these risks is reduced blood supply to the brain. The operation went well and she was taken to the recovery
room. But unfortunately, while she was in the recovery room, she was noticed to have a weakness in one side of her body. So, we requested a
brain scan for her and I am afraid it doesn’t have good news for you. 3rd shot
➢ I am really sorry to tell you that the scan showed that she has suffered a stroke, that is reduced blood supply to the brain. I am afraid to say that
her condition is quite serious, and we had to transfer her to the ITU for close monitoring and support. PAUSE – GIVE TIME TO VENT

Emotions
➢ I am extremely sorry for delivering this news to you.
➢ Can you tell me more about how you feel? I can see that made you very upset. Actually, most of the people would feel that way.
➢ I Know you weren’t expecting this at all. I Know this came as a shock to you.
➢ When she says I don’t know how to…. Answer by ‘Tell me more please about that’ I am really sorry this has happened. I can understand how
difficult and tough this is on you.
Breaking Bad News
BBN – Post operative ischemic stroke – Cont’d

Strategy
➢ Management Usually after the stroke she may develop some swelling in the brain which may take about 2 weeks to reduce and that’s
when we’ll be able to tell how much recovery she can make from this. Let us wait for the specialist review and I will update you after
that.
➢ So, Do you have any concerns at the moment?
➢ Q. Going to die? Ans: I am really sorry that you are feeling that way but unfortunately its difficult to predict at the moment how her
body will react to that as she had a brain surgery followed by a stroke. But hopefully when she is reviewed by the specialist, we’ll be
able to give you more information.
➢ OK, I would just leave you my name again, and if any questions rise up just let me know. Alright, so for now you can wait in the waiting
room if you’d like, and I will come and update you after the specialist has reviewed your mum or if there is any changes.
➢ Is there anything else we can do for you? Anything else you want to discuss?