Breaking bad news is one aspect of practice that many clinicians fear. The thought of telling a patient something they don't want to hear can elicit feelings of anxiety and dread. Even for clinicians who, by the nature of their work, are obliged to have this type of conversation frequently, breaking bad news can be difficult.
And of course, for patients and their families, such news may be devastating. But giving bad news in a sensitive manner can make this extraordinarily difficult situation easier to cope with for patients, their families and for clinicians themselves.
So how do you break bad news? The following six steps may help deliver potentially life-changing information in a sensitive way. The model, known as SPIKES, was first published in The Oncologist in 2000 as a protocol for delivering bad news to cancer patients. However, it has since been adapted to apply more widely to other circumstances as well.
Think about what you want to say in advance, and try to arrange the interview in a way that best allows quiet and considered discussion. Choose a suitable time and place. You may wish to suggest that the patient be accompanied by a friend or relative; this will alert the patient that you intend to have a serious discussion.
You should also consider practical measures such as having sufficient seating in the room, and turning off or muting bleeps and mobile phones. Allow enough time for the patient and their relative to express their emotions and ask questions.
Allow enough time for the patient and their relative to express their emotions and ask questions.
It's helpful to be aware of the patient's understanding of their condition, so that you can tailor how you deliver the information and where to begin. Patients' understanding may differ; family members too may have more or less insight into what is occurring. Before you begin, you may wish to check that the patient is able and willing to hear what you will say.
The patient's relative or other supporter may also need time to process information, and you may wish to check that they too are prepared for you to proceed.
Patients may provide you with an opening or 'invitation' to impart information, or they may try to avoid hearing what you say. You will need to gauge your approach appropriately.
When you give information, try to use language appropriate to the patient's level of education and understanding. Reflecting the patient's words and body language may be helpful. Using words similar to those used by the patient, such as 'lump' or 'growth', can be a useful way to begin the discussion, as it will help keep the conversation at a level suitable for the patient.
Avoid euphemisms which may impair the patient's understanding of what you are saying. Try to tune in to the patient's reaction, so that you can provide information at a pace the patient will understand. Avoid excessive jargon or technical language, which can sometimes be a useful crutch for a clinician but may pose a barrier to communicating with the patient.
It's important for the patient and their relative to have enough time and space to absorb and react to the information, and to ask further questions. If there is any doubt about the diagnosis or prognosis, you must explain this and provide options for clarifying any uncertainty. You should also be able to provide the patient and their supporter with information regarding next steps, such as the dates of follow-up appointments; if this is not possible, provide a realistic timescale of events and reviews. The patient should also be informed who is in charge of their care and how to contact them, should the need arise.
Providing reassurance of ongoing support can help the patient and their family cope with the situation and feel less isolated. Be aware that the patient and their relative may differ in the amount of information they want or need. If you sense that there is a disparity, you should check with the patient that it's okay to speak with their relative separately at the end of the consultation.
Providing reassurance of ongoing support can help the patient and their family cope with the situation and feel less isolated.
It's important that you don't make assumptions about the emotions patients are feeling and the information they might want. You should encourage the patient to express their concerns and respect their views about how much information they are prepared to hear, even if these do not correlate with your own outlook.
However, be careful that in adopting an empathetic approach you do not 'share' the patient's emotions and assume you understand how the patient feels. Instead, it's helpful to validate the patient's emotions, and provide enough time and space for the patient and their relative to express their reactions.
Summary and strategy
A helpful way to ensure the patient has understood what you have said is to ask them to summarise briefly the main points of the conversation. You should also encourage the patient to express any concerns they may have, rather than waiting for them to proactively ask questions. It can be helpful to provide reading material for the patient to absorb when they are ready, and to suggest that the patient write down questions to discuss at your next meeting, so that you can be sure that you are appropriately exploring their understanding.
Breaking bad news does tend to become easier with practise. A considered, compassionate approach can not only ease the distress of patients and their families, but also improve job satisfaction and diminish stress levels for the clinician, making this process easier for both patients and doctors.
Dr Sissy Frank
Dr Sissy Frank
Sissy trained in law in the US, graduating from Stanford University in 1990. She then changed careers and trained in medicine, obtaining an MD from Harvard Medical School in 1998 and completing her residency in paediatrics in 2001. She came to England in 2001 and completed further training in general practice, receiving her MRCGP in 2006. Before becoming an MLA, she worked as a GP partner in Kent.
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