Many clinicians mistakenly believe that experience alone is sufficient to prepare them for sharing bad news. It is also easy to assume that simply lending a sympathetic ear or having compassion for seriously ill patients equips them with the ability to effectively communicate bad news. Although there is little research on this subject, studies suggest that physicians feel inadequately trained in sharing bad news, but after receiving structured training in the area, feel more comfortable engaging in these conversations.1
How Do We Define ‘Bad News’?
While the definition of bad news may seem intuitive, it can actually be any information which is considered by the patient and/or family to be something other than information they desire. For example, delivering any of the following messages could be considered bad news by a patient or family member:
- Current medications are not effective
- New medications may be needed
- A procedure is necessary
- The diagnosis is correct
- The prognosis is accurate
It is also important to remember that communicating bad news affects many other aspects of a patient’s life. It can affect a patient’s capacity to hope, threaten his or her mental well-being, upset an established lifestyle, and limit his or her choices.
The Many Reasons We Avoid It
Besides lacking specific training in the area, medical professionals may avoid sharing bad news for a number of other reasons. We may feel personally responsible for a patient’s misfortune or feel that a poor outcome reflects a practice failure. Clinicians also often worry that sharing bad news will cause adverse reactions in patients, such as anxiety or despair. Finally, unresolved personal issues surrounding the death and dying process can also adversely affect a hospice professional’s ability to communicate bad news.
A 6-Step Protocol that Can Help
Although there is no evidence-based consensus on the best way to share bad news, experience suggests that structured communication is more effective than ad lib discussions. In his book, How to Break Bad News: A Guide for Health Care Professionals, Dr. Robert Buckman proposed a six-step protocol that many find helpful when embarking on a difficult conversation. The protocol uses the pneumonic, SPIKES, to help clinicians remember the content and order of the important steps.
First, ensure the setting is conducive to good communication. Adequate privacy and comfort for the patient and family is essential. Limit distractions by turning off cell phones and pagers, and ask staff members to avoid interrupting the meeting. Invite appropriate loved ones to the conversation but, at the same time, respect the patient’s privacy and autonomy by excusing unwanted family members. Always remember to minimize any sense of power inequity by speaking to patients at their eye level.
Next, elicit the patient’s perception of the current problem. Psychological defense mechanisms, such as denial, can affect a patient’s capacity to understand the prognosis. Furthermore, when patients see multiple specialists it is easy for them to receive inconsistent or even conflicting information. It is unwise to begin sharing diagnostic or prognostic information without first knowing the patient’s current understanding of the circumstances.
Before sharing bad news with patients, obtain an invitation to proceed. Patients who are in pain or experiencing other physical symptoms may want to postpone the conversation. The information will be better understood if the patient is physically and emotionally ready to receive it.
When it is time to share the specific bad news with the patient, share the knowledge in small chunks. It is tempting for clinicians to disclose everything they know about the patient’s condition at once. Sharing too much information at one time reduces the likelihood that a patient will understand and remember the details. Avoid using medical jargon. While this advice is self-evident, it is easy to forget that even what we think of as simple medical terms, like malignancy or prognosis, can be misunderstood by the patient or family member. Stop and check frequently for understanding.
Once you have shared some information about the patient’s condition and checked for knowledge, it is time to begin to understand the impact on the patient. Avoid using trite phrases like “I understand” or “I know how you must feel.” Instead, simply ask how he or she is feeling. Reflect on the patient’s emotions and let the patient know that you understand how and why he or she feels that way. Although it is not necessary to literally assume the burden of the patient’s feelings, if the patient feels empathy, it can be disarming and reassuring. True empathy with the patient or family member can have a powerful impact on the therapeutic relationship. When patients feel they are heard and understood by their caregivers, they are more likely to trust them and follow their advice.
S—Summarize and Strategize
Learning difficult news can be overwhelming to patients and family members. Medical details, particularly when patients are seriously ill, are often complicated. Make sure you end the conversation by summarizing the information and discussing a future strategy.
Supporting Staff Through Training
Consider assessing your hospice team’s comfort with engaging in difficult conversations through a survey; team members will likely express an interest in further training. Share the details of the SPIKES protocol with them and consider role-playing exercises so they can gain perspective on difficult conversations through the eyes of both the professional caregiver and the patient.
Learning how to deliver bad news in a structured manner—so patients and their loved ones are ready to hear the information, understand it, and feel listened to and cared for—can better equip them to make therapeutic decisions that are consistent with their values and the goals of care.
1 Baile, W. F., Kudelka, A. P., Beale, E.A., et al. (1999). Communication Skills Training in Oncology: Description and Preliminary Outcomes of Workshops on Breaking Bad News and Managing Patient Reactions to Illness. Cancer, 86 (5), 887–97.
2 Buckman, R. (1992). How to Break Bad News: A Guide for Health Care Professionals. Baltimore: Johns Hopkins University Press.