Breaking Bad

News
Objectives:
Students will:

• Recognize essential principles of

breaking bad news.
• Identify pitfalls in delivering breaking
bad news.
• Apply skills of breaking bad news in a
simulated situation.
THE BAD NEWS ABOUT BREAKING
BAD

NEWS IS THAT BAD NEWS IS

BAD NEWS
DEFINITION OF BAD NEWS
Bad News

any news that drastically and

negatively alters the patient’s view
of their future

Buckman R. BMJ1984
Bad News

any news that drastically and

negatively alters the patient’s view
of their future

Buckman R. BMJ 1984

Bad News

any news that drastically and

negatively alters the patient’s view
of their future

Buckman R. BMJ 1984

It alters one’s self-image : “I left
my house as one person & came
home another.”
Professional cyclist Lance Armstrong’s
recollection
Examples of Conditions
Requiring Breaking of
Bad News ???!!!!
Examples of Conditions
Requiring Breaking of Bad News

• Cancer related diagnoses

• Intra uterine foetal demise

• Life long illness: Diabetes, Epilepsy

• Poor prognosis related to chronic

diseases: loss of independence
Examples of Conditions
Requiring Breaking of Bad
News(cont)
• Informing parents about their child’s
serious mental/physical handicap

• Giving diagnosis of serious sexually

transmitted disease …catastrophic
psychosocial results

• Non clinical situations like giving

feedback to poorly performing
trainees or colleagues
The Good News! about Bad
News!!!

• Using a plan for determining the

patient’s values, their wishes for
participation in decision making,
and a strategy for addressing their
distress when the bad news is
disclosed can increase our
confidence in the task.
The Good News! about Bad News!!!
(cont)
• It may also encourage patients to
participate in difficult treatment
decisions
• Those who do so have a better
quality of life
• Clinicians who are comfortable with
giving bad news are subject to less
stress and burnout.
Do You Tell??
Do You Tell?

Recent studies have shown that:

• Patients generally (50-90%) desire full & frank
disclosure, though a sizeable minority still may
not want the full disclosure. (Ley p. Giving
information to patients. New York: Wiley, 1982 )

So the issue is not “do you?”

Issue is “how?”
Do You Tell?
In reality, patients who are dying,
know they are dying
 They want confirmation of their
status
 They want a time frame
YOU would want a time frame
when your time approaches
Is this Difficult to break the
bad news?
WHY?
Is this Difficult to break the
bad news?

• It is referred by some physicians

like “dropping the bomb”
Baile W F, oncologist 2000
Why is this Difficult?

Social factors

Our society values youth, health,

wealth
Elderly, sick and poor are marginalized
Sick and dying have less social value
Why is this Difficult?

Physician factors

Fear of causing pain

 Uncomfortable in uncomfortable
situations
 Sympathetic pain due to patient’s
distress
Why is this Difficult?

Fear of being blamed

 Physicians have authority, control,
privilege and status
 When medical care fails patient
it’s physician’s fault
“blame the messenger”
Why is this Difficult?

Fear of therapeutic failure

 Medical system reinforces idea that poor
outcome and death are failures of ‘system’
and by extension, our failure
“all disease is fixable”
“better living through chemistry”
We are trained to feel this way; “if only……”
Why is this Difficult?

Fear of medico-legal system

Everyone has “right” to be cured;

If no cure happens, someone is to
blame
Why is this Difficult?

Fear of not knowing

“we don’t do what we don’t do well”

Good communication is a skill that is
not highly valued, therefore not
taught
Why is this Difficult?

Fear of eliciting reaction

 “don’t do anything unless you
know what to do if it goes wrong”
 Not trained to handle reactions
 Not trained to allow emotion to
come out
Why is this Difficult?

Fear of saying “I don’t

know”

 We are never rewarded for lack of

knowledge
 Can’t know or control everything
Why is this Difficult?
Fear of expressing emotions
 Viewed as unprofessional
 Suppressing emotions increases
distance
between ourselves and patients
Rabow & Mcphee (West J. Med 1999) described:
“Clinicians focus often on relieving patients’
bodily pain, less often on their emotional
distress & seldom on their suffering.”
Why is this Difficult?

Ambiguity of “I’m sorry”

Two meanings
“I’m sorry for you”
“I’m sorry I did this”
Easily misinterpreted
Why is this Difficult?

Fear of one’s own illness and

death

Cannot be honest with the dying

unless you accept you will die
So How Do We Do This??
Never, never, never,
ever…

NEVER “assume”
If you need to know something
If you want to know something
If you need to know something
If you want to know something

ASK!!
THINGS GO WRONG WHEN:

* WE TRY TO ESCAPE

* WE REACT IN ANGER

* WE DILUTE THE AGENDA

THINGS GO WRONG WHEN:
WE TRY TO ESCAPE:

• INAPPROPRIATE DELEGATION
• DISTRACTION
• FRONTAL ATTACK
• INTELLECTUALIZATION
• MINIMIZATION
• EMPTY REASSURANCE
THINGS GO WRONG WHEN:
WE REACT IN ANGER:

• TO DENIAL
• TO IDEALIZATION
• TO REHEARSAL OF THE STORY
• TO ‘UNREASONABLE’ DEMANDS
• TO ANGER AND BLAME
THINGS GO WRONG WHEN:

WHEN WE DILUTE THE AGENDA:

• BILLING

• PRACTICAL ARRANGEMENTS

• REQUEST FOR POST MORTEM

The SPIKES Protocol

• SETTING UP the interview

• Assessing patient’s PERCEPTION
• Obtaining the patient’s INVITATION
• Giving KNOWLEDGE and information
• Addressing the patient’s EMOTIONS
• STRATEGY and SUMMARY
 SPIKES
Step 1: S - SETTING UP the interview
• Preparation Preparation- Preparation
• Always in person, face to face
NEVER on telephone
• Plan, arrange for privacy, involve
significant others
• Sitting down, Non Verbal Behaviour
• Manage time constraints and interruptions
SPIKES
• Step 2: P –
Assessing The PATIENT’S PERCEPTION

• Gather before you Give

• Patient’s knowledge, expectations and hopes
• What do they understand about the situation?
Unrealistic expectations?
• What is their state of mind? Hopes?
• Opportunity to correct misinformation and tailor
your information
SPIKES
• Step 3: I – Obtaining the patient’s
INVITATION
• Gather before you give
• How much does the patient want to know?
Coping strategy?
• Answer questions, offer to speak to another
SPIKES
• Step 4: K – Giving KNOWLEDGE and
information to the patient
• Warning shot
• Use simple language, no jargon,
• Vocabulary and comprehension of patient
• Small chunks, avoid detail unless requested
• Pause, allow information to sink in
• Wait for response before continuing
• Check understanding
• Check impact
SPIKES
• Step 5: E – Addressing the patient’s
EMOTIONS with empathic responses
• Shock, isolation, grief
• Silence, disbelief, crying, denial, anger
• Observe patient’s responses and
identify emotions
• Offer empathic responses
Emotions of the patient
• Respond to patients’ emotions with
empathy
• Often shock, isolation, disbelief, grief or
anger
Observe for emotion on patient’s part
Identify the emotion.
Identify the reason for the emotion
Connect with the patient
Emotions of the patient
• Exploratory questions
How do you mean?
Tell me more about it
You said it frightens you
You said you were concerned about
your children, tell me more
Could you tell me what you are
worried about?
Emotions of the patient
• Validating responses
I can understand how you felt that way
I guess anyone might have the same
reaction
You are perfectly correct to think that way
Your understanding of the reason for the
tests is very good
Many other patients have had a similar
experience
Emotions of the patient
• Doctor: “I’m sorry to say that the X-ray
shows that the chemotherapy is not
working [pause]. Unfortunately, the
tumor has grown somewhat”
• Patient: “I’ve been afraid of this!”
[Cries]
• Doctor: [Moves his chair closer, offers
the patient a tissue and pauses,] “I know
that this isn’t what you wanted to hear. I
wish the news were better”
What is Empathy?

The capacity to recognise emotions

that are being felt by another
person.
Empathic Responses

• An indication to the patient that you

recognise what they are feeling (and
why)
• Verbal and Non verbal
• Often associated with the impact of the
news rather than the understanding.
• Wait for response
• Clarify
Emotions of the patient
Empathic statements

I can see how upsetting this is to you

I can tell you were not expecting to
hear this
I know this is not good news for you
I’m sorry to have to tell you this
This is very difficult for me also
I was also hoping for a better result
SPIKES
• Step 6: S – STRATEGY and
SUMMARY
• Are they ready?
• Involve the patient in the decision making
• Check understanding
• Clarify patient’s goals
• Summarise
• Contract for future
REVISION OF THE 6 STEPS
 Six Step Protocol
-arrange physical context
-find out what patient knows
-find out what patient wants to know
-share information
-respond to patient’s feelings
-plan follow-through
Arrange physical context
Always in person, face to face
NEVER on telephone
Assure privacy
Verify who is present
Verify who should be present
ASK
Arrange physical context
Remove physical barriers
Sit down
patient-physician eyes at same level
appear relaxed, not casual
(avoid ‘open 4’)
Touch patient (appropriately)
above the waist, handshake, shoulder
Find out what patient
knows
Not just knows, but understands

Use open questions

closed questions excellent for
history-taking
prevent discussion
Find out what patient
knows
Listen effectively to response:
tells understanding, ability to
understand
Repeat back what patient says
Do not interrupt
Make encouraging cues
Maintain eye contact
Find out what patient
knows

Tolerate silences

Listen for “buried question”

question asked while you are
speaking
Find out what patient
wants to know

Ask!!
Do not allow families to run
interference

If patient chooses not to know now,

may ask later
Share the information
Plan agenda
know beforehand what information
has to get across
eg diagnosis, treatment, prognosis,
support

Start by aligning with what patient

knows
Share the information

Allow patients to ‘get ready’

Impart information in small packets
best case retention = 50%
Speak English, not “Doctor”
Verify message is received
Respond to feelings

Acknowledge emotions
strong emotions prevent
communication
identify and acknowledge them

Learn to be comfortable with silence and

with emotion
Respond to feelings
Range of normal reaction is wide
give latitude as much as possible
stay calm, speak softly
be gentle, yet firm
stick to basic rules of interview:
question-listen-hear-respond
Respond to feelings
Distinguish between adaptive and
maladaptive behaviors
Adaptive Maladaptive
anger rage
crying collapse
bargaining manipulation
fulfilling an ambition impossible
“quest”
fear anxiety/panic
hope unrealistic hope
Respond to feelings

Respond with empathic responses

“it must be very hard to…”
“you sound angry (afraid,
depressed)…”
Respond to feelings

In the face of true conflict: act, don’t

react

If you cannot change behavior, get

help
Planning follow-through
Have plan of action
Make certain patient’s understand
what is fixable and what is not
Always be honest
Patient leaves with contract:
what will happen, who to call,
how to call, when to return
You have one chance to get this
conversation right
Patient/family will remember this
always

How do you want to be remembered?

How to Break Bad News: A Guide for
Health Care Professionals
Robert Buckman, M.D.
Johns Hopkins University Press, 1992
ISBN: 0-8018-4491-6
• Scenario 1
Tariq, a 55-year-old chain smoker taxi driver
with persistent cough for 3 months, attends
your clinic to find out the biopsy report of a
lesion shown on a chest x-ray and CT scan. He
is rather anxious, that he has a serious
condition.

His biopsy report confirms that he has a

Bronchogenic Carcinoma of right lung.

You are required to proceed with this

consultation.
Scenario 2
• A 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 2 months. She also has a history of Breast
cancer, which was treated 5 years ago.
• Her report shows that she has secondaries all
over her spine
Proceed with this consultation.
(Examination not required)
SAQs
(1) One of the famous strategy for breaking bad
news is the SPIKES Model:
Explain briefly any 3 of the 6 areas mentioned in this
model?

(2) What is a warning shot? What you say and what

skills you use after and before breaking bad news?

(3) Breaking bad news is difficult: Give 3 reasons for

that?