BREAKIN

G BAD
NEWS
A presentation about the provision
of bad news to patients with
empathy, clarity and kindness.
 01 /
What is Breaking Bad News?

02 /
Models of Breaking Bad News

CONTENTS 03 /
Bio-psycho-social, Individualized
disclosure models, etc.

04 /
Challenges of Non-Pharmacological
Interventions
WHAT IS Any news that adversely and seriously
affects an individual’s view of his or her own

BREAKIN future is considered bad news. There are

many clinical situations where bad news

G BAD has to be communicated to patients and/or

their relatives, e.g. disclosing the diagnosis

NEWS? or relapse of cancer, birth of mal formed

baby or death of a loved one.

• Breaking bad news is an unpleasant

task and can be learned from the
senior physicians or through own
professional experience.
• Most patients and families expect
full disclosure delivered with
empathy, kindness and clarity.
MODELS OF BREAKING BAD
NEWS
Bio-Psycho-Social Individualized
01 Model 02 Disclosure Model

03 04
Paternalistic
Full Disclosure Model Disclosure Model

Non - Disclosure
05 Model
 BIO-PSYCHO-SOCIAL MODEL

• This model provides clear, crisp, evidence based information on the

patient’s condition but tailors the information according to the needs
of the patient.
• The parts that the patient or his family have not asked for are avoided.
• The bad news is broken using principles of effective communication,
counselling and informational care.
• The patient is encouraged to involve his family members, particularly
the ones who can provide psychosocial support, during the session as
well as in the long run
 Steps of Bio-Psycho-Social
Model
01 Seating and Setting

02 Patient’s Perception

03 Invitation

04 Knowledge

05 Empathy

04
06 Thinking of harming yourself or others.
Summarize

07 Plan of Action
 STEP 1: SEATING AND
SETTING
(ENVIRONMENT)
Exclusivity
• The environment where bad news is being broken can have serious
repercussions on the outcome of the interview.
• A patient’s mistrust and antagonism may result from a poorly chosen
location.
• A private room where the doctor and patient can focus on the subject
attentively.
 STEP 1: SEATING AND
SETTING
(ENVIRONMENT)
Involvement of Significant Others

• Some patients like to have family members/friends around them

when they receive bad news, while others prefer to hear bad news
alone.
• Ask the patient who they would like to accompany them. If there is
more than one person, ask one to act as representative.
• This gives the patient support and alleviates some stress from the
doctor in the face of an emotionally charged interview.
 STEP 1: SEATING AND
SETTING
(ENVIRONMENT)
Seating Arrangements

• It is advisable for the interview to take place with both doctor and
patient comfortably and respectfully seated next to each other,
preferably at a distance of an arm’s length.
• The arrangement should never impart an intimidating image of the
doctor.
• It should provide an appropriate setting for discussions and any
emotional outbursts or ventilation of feelings that may arise.
 STEP 1: SEATING AND
SETTING
(ENVIRONMENT)
Be Attentive and Calm
• Most doctors feel anxious when breaking bad news and it is worth
spending some time to eliminate any signals that may suggest our
own anxieties.
• Maintain eye contact and show your attention.
• If the patient starts to cry, try shifting your gaze because nobody
likes to be watched while crying.
• This should however be done with sensitivity and must never send a
signal that you do not realty care about the patients feelings.
 STEP 1: SEATING AND
SETTING
(ENVIRONMENT)
Listening Mode Availability

• Silence and repetition of last • If you have appointments to keep,

few words that the patient has give your patient a clear indication
said are two communication of your time constraints but make
skills that will send across the yourself available to the patient for
message that you are listening all his queries and doubts for the
well. duration that you are with him or
her.
 STEP 2: PATIENT’S PERCEPTION

Ask: “What do you know?”

“Aap apni beemari kai baray mai kya jantay hain?”

• The principle involved in this step is “before you tell, ask.”

• Before you break the bad news to the patient, try to ascertain the patient’s
perception of his or her MEDICAL condition. Obtaining this information depends
on your own communication style.
• As your patient responds to your questions take note of the language and
vocabulary that s/he is using and be sure to use the same vocabulary in your
sentences.
• If the patient is in denial, try not to confront him in the first interview, as denial is
an unconscious defense mechanism that facilitates coping.
 STEP 3: INVITATION

Ask: “What would you like to know?”

“Aap beemari k baray mai kya jan’na chahain ge?

• Although most patients want to know all about their illness but assumption
towards that should be avoided.
• Obtaining overt permission respects the patient’s right to know or not to know.
• For example: “Are you the kind of person who likes to know alt the details about
what’s going on?”,
• “How much information would you like me to give you about your diagnosis and
treatment?”,
• “Would you like me to give you details about what is going on or would you prefer I
tell you about the treatments I am prescribing to you?.”
 STEP 4: KNOWLEDGE

Ask: “What have you understood?”

“Kya mal aap ko baat theek se samjha saka/saki hoon?”

• Before you break bad news, give your patient a warning of some sort to help him
prepare e.g. “Unfortunately I have some bad news for you Mr. X” or “I am sorry to
have to tell you...”
• When giving your patient bad news, use language similar to his. Avoid scientific
and technical language. Even the most well informed patients find technical terms
difficult to comprehend in that state of emotional turmoil.
• Give information in small bits and clarify whether s/he understands what you have
said so far, e.g. “Do you see what I mean?” or “Is this making sense so far?”
• As emotions and reactions arise during the interview, acknowledge them and
respond to them.
 STEP 5: EMPATHY

• For most doctors responding to our patients’ emotions is one of

the most difficult parts of our jobs.
• In our effort to alleviate our own discomfort it is tempting to
withhold certain information or give a more hopeful picture than
actually exists.
• These tactics may appear to help in the short term but seriously
undermine your efforts in the long run.
• It is much more useful and therapeutic to acknowledge the
patient’s emotions as they arise and address them.
 STEP 5: EMPATHY

• The technique that is most useful is termed the empathic response.

An empathic response involves listening and identifying the emotion
or mix of emotions that the patient is experiencing and offer an
acknowledgement for them.
• Identify the source of that particular emotion and then respond by
showing that you understand the emotional expression of the
patient.
• Statements such as “mai bhi agar aap ki jagah hon toh aisa he
mehsus karoon” reassure the patient that you understand the
human side of the medical issue and that you have a respect for his
feelings.
 STEP 6: SUMMARIZE

• Before the discussion ends, recapitulate the

information in a short summary of all that has been
discussed and give your patient an opportunity to
voice any major concerns or questions.
 STEP 7: PLAN OF ACTION

• You and your patient should go away from the interview

with a clear plan for the next steps that need to be taken
and the role you both would play, in the management of the
issues. Also allow the patient to have a way of contacting
you, through the hospital exchange or after rounds the next
morning, in case they have any questions.
 INDIVIDUALIZED DISCLOSURE
MODEL
• In this model the amount of information disclosed and the rate of its
disclosure are tailored to the desires of the individual patient by doctor-
patient negotiation.
• First the doctor and patient work together to clarify what information the
patient wants.
• The doctor then imparts that information in a way that the patient
understands.
• This is an on-going and developing process. It implies a level of mutual trust
and communication that takes time and effort to develop.
• The distinguishing features of this model are that it takes time and skills and
its assumptions are supported by evidence. It has the capacity to maximize
quality of life for the patient.
 INDIVIDUALIZED DISCLOSURE
MODEL
• The underlying assumptions in this model are that it takes each individual a
different amount of time to absorb and adjust to bad news.
• A partnership between the doctor and the patient for decision making is.
therefore, in the patient’s best interest.
• Its disadvantages are that it is a time consuming process that might be difficult
for a busy physician to undertake. It also tends to drain a health care
providers’ emotional resources.
• The advantages are that the amount of information given and rate of
disclosure is tailored to needs of the individual and a supportive relationship
with the doctor is established.
 FULL DISCLOSURE MODEL

• This model involves giving full information to every patient as soon

as it is known.
• It argues that this promotes doctor-patient trust and
communication and facilitates mutual support within the family
unit.
• The assumptions in this model are that the patient has a right to
full information about himself and the doctor has an obligation to
give it.
• It assumes that all patients want to know bad news about
themselves and that patients themselves should decide what
treatment is best for them.
 FULL DISCLOSURE MODEL

ADVANTAGES DISADVANTAGES

• It includes promotion of doctor-patient • Discussion of options in detail may

trust, family support and allowing frighten and confuse some patients.
patients time to put affairs in order in • The doctor insisting on providing
case of a poor prognosis. information may undermine defenses
• It also helps those patients who cope such as denial which are otherwise
better with their diagnosis by having the important for the survival of the patient.
maximum amount of information about • The provision of full information may,
their illness. also, have negative emotional
consequences for some.
PATERNALISTIC DISCLOSURE MODEL

• This model implies that information about the patient’s disease is

the right of the doctor.
• The doctor delivers the information to the patient as and when
s/he deems appropriate, in a ‘sugar coating’ to minimize the pain
and distress of the patient.
• It also involves the expression of sympathy and a sharing of
emotions on the part of the doctor.
• This model is no longer recommended for use.
 NON-DISCLOSURE MODEL

• This model is based on the view that under no circumstance should

patients be informed that they have acquired a lethal disease.
• It states that deception should be used if necessary, on the basis
that the patient needs protection from the terrible reality of
terminal illness.
• This model has been traditionally adopted as part of a paternalistic
and nurturing attitude of doctors towards their patients.
• The underlying assumptions in this model are that it is appropriate
for a doctor to decide what is best for the patient; patients do not
want to hear bad news and they need to be protected from it.
NON-DISCLOSURE
MODEL

ADVANTAGES DISADVANTAGES

• Denial of the opportunity to

• it is easier and less time adjust to illness

• trust in doctor is undermined
consuming for the doctor and
opportunities for helpful
suits those people who prefer
interventions are lost
not to know their condition.
• patient compliance is less likely
• patients may acquire wrong
information that can lead to
avoidance, isolation and a
perception of rejection.
What expectations do the patient and family have when receiving
bad news?

• According to research, the most important factor to the patient and

family receiving bad news, is the attitude of the health professional.
The health professional should, thus, be knowledgeable,
empathetic and give honest and clear answers in simple language.
• The second most important factor is the setting in which the news
is broken. A quiet, private place where the news is broken in an
uninterrupted way is preferred.
What are the common reactions that a patient experiences upon
receiving bad news?

• The reactions that a person goes through when they hear bad
news, can be summarized as the stages of denial, anger,
bargaining, depression and acceptance.
• These stages are rarely clearly delineated, and often patients go
through one or more stages at the same time and for each
individual the length of time each stage lasts may vary.
• It is important that the health professional empathize with and
provide support for the patient during each stage.
What are the common reactions in a health professional breaking
bad news?

• Delivering bad news can be equally taxing and demanding for the
health professional. S/he may experience strong emotions of being
a failure, or of not having done enough for the patient.
• Feelings of helplessness, sadness and fear that they may harm the
patient emotionally by telling them the truth may be experienced.
• Some may feel shame and disillusionment with their profession,
and others may experience fear of their own death and disability.
 CHALLENGES OF NON-
PHARMACOLOGOLICAL INTERVENTIONS

• The biggest hurdle in the administration of any non-pharmacological

intervention is the lack of time.
• In busy clinics and overcrowded wards where patients go from being
humans with names to beds with numbers, it seems impossible to
find the time to give someone all they need.
• It seems to suffice that we are there at alt, that we are doing the bare
minimum to keep afloat in the never-ending sea of patients.
• Research shows that by not spending the required amount of time the
first time we see a patient, we tend to misunderstand. misdiagnose
and mistreat
• Breaking bad news is another time-consuming procedure,
however, one of utmost importance. To inform an individual
that s/he may have cancer or AIDS is to inflict a major
psychological trauma. People will remember, for the rest of
their lives, the details of the occasions when important news
was broken. A health professional must think for a moment
how they would feel if they were to receive such news. There
is a world of difference between the doctor who breaks this
news in relaxed atmosphere with a supportive attitude and
the callous consultant who flings bad news at the patient in a
public ward.
• Before telling people what we think they need to know, we should find out what
they already know, or think they know, about the situation and what their
priorities are. If they use words like cancer’ or death’, we should check out that
these words mean the same to them as they do to us. ‘There are many kinds of
cancer, what does the word mean to you?’. ‘Have you seen anyone die? How do
you view death?’ will often reveal considerable ignorance and open the door to
positive reassurance and explanation. Too often, doctors fail to invite questions
and miss the opportunity to help people with the issues that are concerning
them most. The patient has a right to know the truth about an illness, but we
must respect their right to monitor the amount of new and painful information
that s/he can cope with at any given time. It is just as wrong to tell people too
much, too soon, as it is to tell them too little, too late.
• Life-threatening illness can undermine our confidence and trust and members
of the caring professions can do a great deal to help people through these
psychosocial transitions. Accurate information is essential to planning. Many
patients may react with relief when they are told they have cancer, as without
any information they have already imagined the worst. It is easier to cope with a
legitimate diagnosis than to live in an unplanned state of uncertainty.
• Many of the different ways people cope with threats reflect the coping strategies
that have been found to minimize stress early in life. At times of threat, those
who lack confidence in their own resources may seek help of others, express
clear signals of distress and cling inappropriately. Those who lack trust in others
may keep their problems to themselves, bottle up their feelings and blame
healthcare providers or therapies for their symptoms. Their lack of trust makes it
necessary for them to control us rather than be controlled by us. A few, who lack
trust in themselves and others. may keep a low profile, turn in on themselves
and become anxious and depressed. To those who lack self-esteem the most
important thing we have to offer is our esteem for their true worth and
potential. To those who lack trust in others we can show that we under stand
their suspicion and their need to be in control of us. Doctors must act as
advisors rather than instructors and show that they accept that trust must be
earned: and that ‘it is not our right to be trusted’.