Breaking Bad News Dr. Saleh M. Aldaqal MBBS, FRCSI,SBGS Assistant Professor and Consultant General And laparoscopic Surgery(France), Department of Surgery, Faculty of Medicine, King Abdulaziz University. www.dr-aldaqal.com

Definition Any information which adversely and seriously affects a patient’s view of his or her future. One of the most difficult areas within the job of a doctor

Examples of bad news Telling a patient that they have cancer. Telling a patient that they are HIV positive. Telling a couple that they cannot have children. Telling a spouse that their husband/wife has Alzheimer’s.

The news is given by the doctor has a major impact on the patient, so it is important that the information is conveyed in the most appropriate manner. Bad news should be given directly to the patient, unless the patient has expressly instructed that the information is given to a family member, or the patient has impaired understanding due to a psychiatric disorder, confusion or altered levels of consciousness.

How Should Bad News Be Delivered? Preparation : Yourself, Setting, Patient The interview: Providing information, Support, Plan Documentation

Preparation Yourself - Familiarize yourself with the patient’s records, so that you are aware of the history and investigations up to this point. - Rehearse the discussion either on your own or with a colleague. - Arrange for a colleague such as a member of the nursing team to be present for the interview.

Preparation (Yourself) Consider your own feelings and emotions about the case in order to set them to one side as much as possible.

Preparation (Setting) Organize privacy – preferably in a separate room. Ensure chairs are available so that everyone present can sit down. Ensure that the time is protected – if necessary, ask a colleague to hold your bleep so that there are no interruptions.

Preparation (Patient) Introduce yourself to everyone Check whether the patient requires a family member or close friend to be present at the interview. If Arabic is not the patient’s first language, ensure that the appropriate translation service is available.

The interview Ask what the patient or family already knows. Provide a warning that the news is going to be bad. The use of phrases such as “I’m afraid that it looks more serious than we had hoped….” can be useful at this point. Then provide the basic information in a simple, straightforward and honest way. Avoid the use of jargon and repeat important points.

The interview Avoid the use of terms like “There is nothing more that we can do…” as there will be plenty more that can be offered, for example, in terms of palliative care – symptom control and emotional support.

The interview Allow the patient the opportunity to ask questions at various points of the interview. Don’t avoid questions because you may not know the answers. If you do not know the answer, then offer to ask another member of the team.

The interview Be prepared to come back to the patient on another occasion to repeat the information in order to improve clarification. During the interview, it is important to offer to speak to members of the patient’s family, with the patient’s consent, as the patient may perceive this as quite a burden

Support Use touch when appropriate. avoid using the term “I know how you feel”. The use of a phrase such as “I can understand how difficult this must be for you” does however convey empathy and support.

Support The patient may show a variety of emotions, including disbelief, shock, anger, guilt and blame. The patient may cry, so be prepared to give them time to do so, and have tissues available. You may need to give permission to the patient to express their emotions. “I’m sorry – the news can’t be easy for you”.

Plan One of the important outcomes of the interview is to leave the patient with a plan for what is to happen next. Providing the patient with a clear plan will help to reduce their anxieties and worries. offer clear support to the patient by using phrases such as: “We can work on this together…” or “Between us, we can….”

Plan summarize and check understanding with the patient. Offer further times to discuss questions and concerns. It is important to identify support mechanisms for the patients such as friends and family.

Documentation It is vital to communicate with the rest of the team after the interview. Document key details of the conversation in the patient’s notes.

The ABCDE Mnemonic for Breaking Bad News Advance preparation TABLE 1 The ABCDE Mnemonic for Breaking Bad News Advance preparation Arrange for adequate time, privacy and no interruptions (turn pager off or to silent mode). Review relevant clinical information. Mentally rehearse, identify words or phrases to use and avoid. Prepare yourself emotionally. Build a therapeutic environment/ relationship Determine what and how much the patient wants to know. Have family or support persons present. Introduce yourself to everyone. Warn the patient that bad news is coming. Use touch when appropriate. Schedule follow-up appointments. Communicate well Ask what the patient or family already knows. Be frank but compassionate; avoid euphemisms and medical jargon. Allow for silence and tears; proceed at the patient’s pace. Have the patient describe his or her understanding of the news; repeat this information at subsequent visits. Allow time to answer questions; write things down and provide written information. Conclude each visit with a summary and follow-up plan. Deal with patient and family reactions Assess and respond to the patient and the family’s emotional reaction; repeat at each visit. Be empathetic. Do not argue with or criticize colleagues. Encourage and validate emotions Explore what the news means to the patient. Offer realistic hope according to the patient’s goals. Use interdisciplinary resources. Take care of your own needs; be attuned to the needs of involved house staff and office or hospital personnel. Adapted with permission from Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients that suffer. West J Med

An old man visits his doctor and after thorough examination the doctor tells him: “I have good news and bad news, what would you like to hear first?” Patient: “Well, give me the bad news first.” Doctor: “You have cancer, I estimate that you have about two years left.” Patient: “Oh no! That’s awefull! In two years my life will be over! What kind of good news could you probably tell me, after this??” Doctor: “You also have Alzheimer’s. In about three months you are going to forget everything I told you.”

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