Breaking bad news

Many of us may have been involved, one way or another, in having to break bad news to someone at one point or another in our lives. But it is often a skill that many of us lack, as we have never had to break bad news directly, or else we have not had to do it very often.
Breaking bad news is always difficult and is rarely something that comes easily, even to very experienced medical professionals.

As students, you may have been very lucky, never having had to break bad news to anyone. As doctors, however, breaking bad news is something that, sadly, has to be done on a regular basis. Because of this, breaking bad news can sometimes form a role-play activity in some medical school interviews.

You may be asked, for example, to break bad news to a patient, a friend or a neighbour.

It could be a medical or non-medical scenario you are asked to role play.

In a non-medical scenario, for example, some students were once asked to role play a scenario where they had to break the news to a neighbour that they could no longer look after their dog, when the neighbour went on holiday, despite having promised to do so.

In a medical scenario, other students have been asked to inform their ‘patient’ that they have a life-limiting illness.

During the role play the ‘patient’ may deliberately display anger, fear, or may be very upset. They may demonstrate surprise on receiving such a diagnosis, or else they may be anxiously wanting further information about their diagnosis. ‘How long have I got?’ is a question they might be asked.

Skills required

You need to be ready to deal with whatever questions might be asked and whatever emotions might be displayed. To do so effectively, you will need to demonstrate both emotion and sensitivity.

It is important to be sensitive and to be kind, but to ensure that the person you are breaking the bad news to understands what you are saying throughout the process. At the same time, however, you have to do this without you being too direct. It can help to imagine you are talking to a close friend or family member.

Communication is key, and it is always very important that you speak clearly in order to avoid misunderstanding.

Remaining calm and speaking slowly, yourself, will help to keep your ‘patient’ calm.
Be very careful not to show your own nervousness, by speaking quickly, or awkwardly, or without confidence. Even if you are finding the situation very difficult, do not let your patient see your stress, as they may mirror your response.

Giving people plenty of time to process what you are telling them can be very helpful. Allowing your patient to have loved ones with them can also help, as the person receiving the diagnosis might not take everything in, so having someone else present is often a good idea. It’s also important to allow your patient to have someone with them for emotional support. This is especially the case if you are breaking very bad news, such as telling someone they have cancer, so always ask your patient if they would like to have someone in the room with them.

Be concise and clear. Ensure your patient understands every stage before moving onto the next.

In the case of a very bad diagnosis, do not overload your patient with detailed information at this early stage. Remember, your interaction is very likely to be only the first stage of many consultations.

The Spikes Model

The SPIKES model was first published in The Oncologist in 2000 as a protocol for delivering bad news to cancer patients. Since then it has been adopted more widely, and is used by clinicians in various circumstances to communicate difficult news to patients in a clear, supportive and compassionate way.

There are 6 steps or stages to the process:

STEP 1: SETTING UP the Interview
STEP 2: Assessing the patient’s PERCEPTION
STEP 3: Obtaining the patient’s INVITATION
STEP 4: Giving KNOWLEDGE and information to the patient
STEP 5: Addressing the patient’s EMOTIONS with empathic responses
STEP 6: STRATEGY and SUMMARY

Here is an example of the SPIKES model in practice:

S – Setting
First, choose the right setting and time to speak to your patient.

• Choose a time when you can speak to them for as long as they need.
• Ensure the room is private with no interruption. Tell staff members that you need privacy.
• Next, make sure that everyone who needs to be present is there.
• Before breaking the news, make sure proper introductions are made with everyone.
• Ensure everyone is seated and comfortable.

P – Perspective/Perception
Find out what your patient knows, or suspects, by asking questions such as:

• How do you feel?
• What do you know about your illness?
• Do you know why Dr Jones has sent you to see me?
• Tell me what you know about your mother’s health.

I – Invitation
Determine how much the patient or their family wants to know about their situation. Patients have the right to know about their condition. They may only want generality without details. Some may want to know everything possible regarding their illness and treatment.
Ask questions such as:

• We have these lab tests back. Can we talk about them?
• How much would you like to know about your illness?

K – Knowledge
Once you understand the level of information your patient wants, it is time to deliver the news and inform them about their health.

• Give them information in small chunks, then pause to give them time to digest what you have told them, or to ask questions. Pausing also gives you the opportunity to check that they are processing the information.
• Check how you are delivering the information by asking if you are making sense.
• Repeat important points to ensure the patient can comprehend information.

E – Empathy/Emotion
While sharing information, you also need to be empathetic. Some patients will have an emotional response, others won’t. There is no way to predict how your patient will feel.
If your patient does react strongly, use the NURSE technique to respond to their anger (you can ready more about this technique online). Help them normalize how they feel, respect their emotions and help support them.

• Naming
• Understanding
• Respecting
• Supporting
• Exploring

S – Summary/Strategy
Use simple clear statements to convey that the whole team is on their side to help. Develop a plan for going forward and answer any questions they have.

Helpful questions to ask / useful things to say:

• Give your patient the opportunity to ask if there was anything they did not understand, and, if there is, take the time to go over it again.
• Ask them how they feel. Is there anything they are concerned about?
• Even with the worst diagnoses, always tell you patient that you and your team are not giving up on treatment.
• Tell you patient that they are not alone and that a support team will be put in place.
• In case they didn’t take in all the information, tell your patient that they can come back, either by themselves, or with a family member or friend to talk further to the team.
• Finally, even with the worst news, never leave things on a negative note, but find a positive way to end