BREAKING BAD NEWS

Rizul singh 82
Sahil verma 85
Sakshi sharma 86
Outline;:
 Introduction
 What is bad news
 Examples
 Clinical case scenario
 Approach to the case
 ABCDE strategy
 SPIKES strategy
 CONES strategy
 Obstacles to communicate of bad
news
 Words to avoid

 INTRODUCTION
Breaking bad news to patients has
been a subject of professional concern
for many years, interest growing
alongside a culture of increasing
medical disclosure of diagnosis and
prognosis

The life of a sick person can be

shortened not only by the act, but also
by the words or the manner of a
physician. It is, therefore, a sacred
duty to guard himself carefully in this
 What is a bad
news?
 Any news that seriously and
adversely changes the patient’s
views of his/her future.
 Situations where there is either a
feeling of no hope,
 A threat to persons mental or
physical wellbeing,
 Risk of upsetting an established
life style, or where a message is
given which conveys to an
individual fewer choices in his or
 Examples of bad
news ;
These include:
 Cancer diagnosis
 Intra uterine foetal death
 Life long illnesses e.g. Diabetes,
hypertension, HIV, infective hepatitis,
 Poor prognosis related to chronic diseases
e.g. heart failure, stroke
 Informing parents about their child’s serious
mental/physical handicap
 Disease recurrence
 The presence of irreversible side effects
 Results of genetic tests
 Death
CLINICAL SCENARIO

54 year old lady attends your clinic to

find out the result of an MRI of her
spine, she has had constant pain all
over her spine for the last 2months,
she also has a history of breast
cancer which was treated 5 years ago

■ Her report shows that she has some

secondaries all over her spine
Strategies for breaking bad news
Different strategies have been applied by doctors
and these includes
 SPIKES
 ABCDE
 BREAKS
 CONES
SPIKES and ABCDE appear to be the most
commonly used
 ABCDE strategy
 A = Advance preparation
 B= Build a therapeutic environment/relationship
 C= Communicate well
 D= Deal with patients and family reactions
 E= Encourage and validate emotions.
 A– Advanced preparation
 Familiarize yourself with the relevant clinical in
formation e.g. investigations ,hospital report etc
 Arrange for adequate time and privacy comfortable
environment
 Instruct staff not to interrupt
 Be prepared to provide at least basic information
about progress and treatment options (read it up if
need be)
 Mentally rehearse how will deliver the news
 Script specific words and phrases to use or to avoid
 Know your patient well so that you will be speaking
to the patient not the diagnosis
 B-- Build A Therapeutic Environment/
Relationship
 Introduce yourself to the patient and
everyone present
 Determine patient preferences for what and
how much he/she wants to know
 Summarize what has happened to date, check
with patient /relative .
 Pay attention to verbal and non verbal cues
 Avoid inappropriate humor
 Assure patient that you will be available
 C-- Communicate Well
 Speak frankly but with compassion
 Determine the patients knowledge and
understanding of the situation
 Proceed at the patients pace
 Allow for silence and tears
 Have patient describe his /her understanding
of the information given
 Encourage and answer questions
 Provide written /drawn information to
encourage Understanding and remembrance
 D-- Deal With Patient And Family
Reactions
 Assess and respond to emotional reactions
 Be empathetic
 Be aware of cognitive coping strategies
 Allow for “shut down” when patients turn off
and stops listening
 Don’t argue with or criticize colleagues
 E-- Encourage And Validate
Emotions
 Offer realistic hopes and encouragement
about what options are available
 Explore what the news means to the patient
 Discuss treatment options
 Use multidisciplinary services e.g. hospice
care, spiritual leader
 SPIKES PROTOCOL
 It centers on defining the central element of the bad
news ,that is what makes it bad news to the patient
and addressing it as well as acknowledging patients
concerns and emotions
 S-- Setting up the conversation
 P-- Perception
 I-- Invitation by the patient (Involving the patient)
 K-- Knowledge to the patient
 E-- Emotions and Empathy
 S-- Strategy and summary + (Self reflection).
 SETTING
 PRIVACY– find a private location such as an
interview room, your office with the door closed or
curtains drawn around a bed
 Ask the patients permission to turn off the TV or the
radio to minimize distraction
 Where the news is broken can have significant effect on
the outcome of the interview
 INVOLVE SIGNIFICANT OTHERS—
 Some patients may or may not like to have family
members or friends around with them
 If there are a number of people closely supporting the
patient ask your patient who will act as a spokesperson
for everybody during the discussion
 This gives your patient support
 LOOK ATTENTIVE AND CALM
 Maintain eye contact. this assures patient that you are listening
 If the patient becomes tearful ,is a good idea to break eye
contact momentarily
 LISTENING MODE
 This involves
 SILENCE– this means not interrupting or overlapping the
patient when he or she is talking .This shows respect to what
patient is saying.
 REPETITION– Repetition involves using the most important
word from the patient’s last sentence in your first sentence,
e.g.. Patient : I am fed up with this treatment
Doctor :Which aspect of the treatment makes you fed up.
 Nodding
 Smiling ( appropriately)
 Saying things like “HMMM”

AVAILABILTY
 Make arrangement for the phones to be answered by
other staff members or voice mail.
 Make sure staff members do not interrupt the
meeting
 P --PERCEPTION
 Assess the patients understanding or the seriousness of their
condition.
 Ask what the patient and family already know
 “Tell me what you understand about your condition so far”
 “what did you think was going on with you when you felt
the lump”
 Assess the patient and family members level of
understanding.
 Take note of discrepancies in the patient’s understanding
and what is actually true. Correct misinformation if
possible.
I-- INVITATION/INFORMATION
 This step is center of “the before you tell, ask”
principle
 Although most patient want to know all the details
about their medical situation, you can’t always assume
that is the case.
 Obtaining overt permission respects the patients right
to know (or not to know).
 Accept the patient right not to want to know, but offer
to answer any question he or she have later eg
 “How much information would you like me to give
you about your diagnosis and treatment.”
 “ would you like me to give you details of what is
going on or would you prefer that I just tell you about
the treatment I am proposing.”
 K—KNOWLEDGE
EXPLAINING THE FACTS
Before you break bad news, give your patient a warning that
bad news is coming.
 This gives your patient a few seconds longer to prepare
psychologically for the bad news.eg
 “Unfortunately, I ve got some bad news to tell you”
“it looks like the result is not very good”
Use the same language as your patient when giving your
patient bad news, this involve aligning or matching
terminology with patient,
 Avoid technical scientific language as much as possible eg
Instead of “metastasized” – say “spread”.
 E-- EMPATHY AND EMOTION
Have an emphatic response to patients problem, the emphatic response
is a technique or skill , not a feeling,.
 Acknowledge patients emotions as they arise and address them.
 The emphatic responses comprises of 3 straight forward steps.
 Step 1 : listen for and identify the emotion (or mixture of emotion)
 Step 2 : Identify the cause or source of the emotion, most likely the
bad news the patient received
 Step 3: Show your patient that you have made the connection between
the above two steps, that is that you have identify the emotion and its
origin.eg
 “Hearing the result of the bone scan is clearly a major shock to you”
 “Obviously this piece of news is very upsetting”
 Validate or normalize the response, you might use such phrase as,
 “I can understand how you can feel that way”
 “I think your anger is a very normal response in the circumstance ”
 SOME EMOTIONAL REACTIONS
FROM PATIENT
 In an emotionally charged scenario, it is very often helpful to
address the emotional first and the issue second.
 This makes patient feel that he or she has been listening to
and heard, it is an important component of support
 CRYING – Crying is a symptom , it usually express distress,
pain or anger (But also joy).
 Offer tissue if it is available
 Remember to break eye contact momentarily – no one like to
be seen crying because he or she feels particularly vulnerable.
 DENIALS - “It is not me , the lab must have mixed up the
specimen”
 ANGER - “ Why was this not seen earlier”
 NUMBNESS
S-- STRATEGY AND SUMMARY
STRATEGY
Decide what the best medical plan would be for the patient.
Recommend a strategy on how to proceed .
Ask the patient to repeat to you their understanding of the plan
Possibly have a clear treatment plan in writing for the patient to take
home with him
SUMMARY
 Summarize the conversation
 Focus on your goals
 Offer to answer questions (be prepared for tough questions)
 Explore patients agenda (ICE)
 Ideas – what may help
 Concerns – what is worrying them
 Expectations – what are their hope for the future
 Assure the patient that you will be available as well as your team to
offer any help possible
 BREAKS

B – Background - In depths knowledge of the patients problem

R – Rapport - The physician should establish a good rapport
with the patient.

E – Exploring - Find out what patient ,knows about the illness,
identify potential conflicts between the patients belief and the
diagnosis, if patient allows you, involve significant others
 A - Announce - Give a warning, short information should be
given in easily comprehensive sentences , a useful rule of thumbs is not
to give more than three pieces of information at a time.
 K – Kindling - Observe patient’s response, his or her
emotional reaction and kindle the emotion.
 S – Summarize – Summarize just as in the SPIKES
strategy
 THE CONE PROTOCOL
Used in the following situations
1. Disclosing a medical error
2. Sudden deterioration in the patients medical condition
3. Sudden unexpected death
Note:
The news should be delivered by the most senior person on
the patients treatment team.
C - Context
O - Opening Slot
N – Narrative
E – Emotions
S – Strategy and summary
 THE ANGRY PATIENT
WHAT TO DO
 Acknowledge the person’s anger
 Try to find out the reason for his anger e.g.. Frustration , fear or guilt.
 Validate his feelings
 Let him ventilate his anger or any feeling that led to the anger.
 Offer to do something or for him to do something.
HOW TO DO IT
 Sit reasonable close to patient ( not too close, not too far),and maintain eye
contact
 Speak calmly without raising your voice
 Avoid dismissive or threatening body language
 Be empathetic
 be aware of your safety
 WHAT NOT TO DO
 Glare at the person
 Confront, interrupt or touch him or her
 Put the blame on others or seek to exonerate yourself
 Make unreasonable promise
 OBSTACLES TO COMMUNICATION OF BAD NEWS
Medical education doesn’t teach it well enough
 There is Unrealistic expectation of the healthcare system by
society
 Cultural differences in disclose of ,information
 Time limitations of medical staff
 lack of trust in the medical system
 lack of experience with issues related with death and dying
 Emotions such as Fear of the process of dying, of blame,
of not having all the answers, emotional out burst
 Sadness ,guilt ,failure, helplessness
 No one wants to be the bad guy.
 Some families don’t want the patient to hear truth as it
stands”
 WORDS TO AVOID.
 “ I cant care for you anymore” you may mean well in terms
of wanting to refer to a specialist but say it in a better way
 “ there is no more hope” there can always be a shifting of
hope NOT NO HOPE
 “ It is time for us to stop treatment”(what about pain and
palliative drugs)
 “ There is nothing more we can do for you” There is always
something that can be done e.g. pain management ,periodic
tapping of ascitic fluid, yoga.etc
 “ Instead of saying “I am sorry” you may say “I wish things
were different”
 IN CONCLUSION
Breaking bad news is frequently a tense and
distressing experience for both the patient and the
physician.
 Your patients emotional responses will be difficult
to withstand unless you have a strategy news
 Know the facts (patient details, expectations,
culture, religious inclinations)
 Acknowledge the limitations of a physician and
medical science in general
 Finally practice communicating clearly,
completely and compassionately.
..


THANK YOU FOR

YOUR TIME