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

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

What is breaking bad news Traditional view moment doctor diagnosis, prognosis or treatment one to one consultation The HCP acts as witness to what has been said provides support once the consultation is over

What is breaking bad news “Modern view” range of HCPs involved information that can be classified as bad news a process multiple episodes of information provision often “ad hoc” not part of a pre-planned consultation before, during and after bad news is given

What could classify as bad news 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

What could classify as bad news? Examples informing relatives of deterioration or death, moving into a residential home, explaining the details of arduous treatment providing daily updates when a patient’s condition is not improving explaining transitions in care from curative to palliative to end of life failed discharge plans telling someone they can’t drive any more

What is bad news – it depends! the same information could be interpreted as good, bad or neutral by different people influenced by 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?

Breaking bad news is a process Not about a single consultation This is an important part Dewar’s work in spinal injury Initial moment then 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

What activities could be described as part of the process of BBN? Preparation During After

Preparation Assessing needs for further information; recognising their cues and prompts Working with the patient and family to achieve consensus with issues about disclosure Identifying and prioritising the patient’s preferences for information Liaising with the healthcare team to initiate discussions where the need is identified or requested Coaching and supporting those who find it difficult to ask questions or talk to the doctors

During 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

After Listening to and acknowledging the emotional reactions of patients and relatives to bad news Explaining and discussing the information received and its implications Answering questions as they arise, identifying and clarifying misunderstanding and explaining complex medical terminology Providing information about the next steps in the care pathway

Other activities around BBN? Supporting decision making about care Explaining complex issues e.g. what is meant by DNAR, informed consent, advanced care directives Support with realising the implications of their situation /the information 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

Why is BBN important? Patient preference 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

What are the negative consequences of not providing patients with bad news? Treatment and decision making End of life care Family and relative dynamics disclosure issues – not tell family, not tell patient Staff in the healthcare team

Impact on treatment and decision making Confusion over the intention and aim of treatment Having inappropriate and unnecessary treatment False optimism Being unable to marry what is happening with the information received Patients not able to participate in decision making Unnecessary anxiety in worrying about the unknown

Impact on end of life care Patients and families deprived of essential time before deterioration Preventing the discussion of end of life preferences Patients not having the chance to get their affairs in order

Impact around disclosure – family and relatives Feeling isolated and unable to communicate with each other Unnecessary strain on family relationships Families carrying the burden of deception

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

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 In some cultures it can be common for the family to be given the information while the patient is shielded from the full facts. However, individuals are not cultures Patient preferences for information should guide the content, timing and delivery of information

Challenges of BBN Does BBN destroy hope?

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?

Reframing hopes and goals (Campbell 2010) “When we worry about destroying hope we often mean a specific hope of getting better or living longer” hope is complex, multi-dimensional and flexible The source of hope can change E.g. from hoping for a cure...to hoping to go home reframing of goals to meet the realities at hand Even though it is a reality not wished for

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 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

Summary – Bad news includes many different types of information Information is defined as “bad news” by individuals 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 HCPs carry out a wide range of diverse roles in relation to BBN

Final notes The way that significant information is given is important 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 are available These will be explored in the next section of the study day